Columtjia  ®nit)ers;itpi  \ 

mtf)eCitj>of^etD|9orb      ^ 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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VENEREAL  DISEASE 


A  MANl  Al.  FOR  STUDENTS  AND  IMIAOTITIONERS 


BY 

JAMES   R.  HAYDEN,  M.D.,  F.A.C.S. 

PROFESSOR    OF    UROLOGY    AT    THE    COLLEGE    OF    PHYSICIANS     AND    SURGEONS 
COLUMBIA     UNIVERSITY,    NEW    YORK;    VISITING    GENITO-URINARY 
SURGEON  TO  BELLEVUE  HOSPITAL;   CONSULTING  GENITO- 
URINARY SURGEON  TO  ST.  JOSEPH'S  HOSPITAL, 
YONKERS,   NEW  YORK 


FOURTH  EDITION,  THOROUGHLY  REVISED 


ILLUSTRATED  WITH    133    ENGRAVINGS 


LEA   &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1916 


Entered  according  to  the  Act  of  Congress,  in  the  year  1916,  by 

LEA   &   FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE. 


In  the  preparation  of  the  fourth  edition  of  thi.s  manual, 
the  author  has  endeavored  to  emphasize,  as  before,  the 
practical,  clinical  aspects  of  the  subjects  under  discussion. 
Only  those  methods  of  diagnosis  and  treatment  have  been 
included  which  the  personal  experience  of  the  writer  has 
proved  to  be  useful  and  efficient. 

The  number  of  illustrations  has  been  more  than  doubled 
and  the  vast  majority  of  them  are  original.  The  text  has 
been  completely  revised  and  the  greater  part  rewritten. 

The  author  takes  pleasure  in  acknowledging  his  indebt- 
edness to  Dr.  Rolfe  Kingsley,  Assistant  Chief  of  Chnic  at 
the  Vanderbilt  Clinic,  for  his  assistance  in  the  revision  of 

the  text. 

J.  R.  Haydex. 
121  West  55th  Street, 
New  York,  1916. 


CONTENTS 


CHAPTER  I. 
Gonorrhea 17 

CHAPTER   II. 
Acute  Gonorrhea 24 

CHAPTER  III. 
Treatment  of  Acute  Anterior  and  Posterior  Gonorrhea      32 

CHAPTER  IV. 

Complications  of  Acute  Anterior  Gonorrhea  and  Their 
Treatment 51 

CHAPTER  V. 

Complications  of  Acute  Posterior  Gonorrhea  and  Their 
Treatment 63 

CHAPTER  VI. 
Chronic  Anterior  and  Posterior  Gonorrhea       ....       84 

CHAPTER  VII. 
Treatment  of  Chronic  Anterior  and  Posterior  Gonorrhea      89 

CHAPTER  VIII. 
Gonorrheal  Ophthalmia 104 

CHAPTER  IX. 
Gonorrheal  Arthritis 107 

CHAPTER  X. 
Stricture  of  the  Urethra 115 


VI  ,  CONTENTS 

CHAPTER  XI. 
Symptoms  of  Stricture 127 

CHAPTER  XII. 
Complications  of  Stricture 130 

CHAPTER   XIII. 
Diagnosis  of  Stricture 138 

CHAPTER  XIV. 
Treatment  of  Stricture 151 

CHAPTER  XV. 
Retention  of  Urine 176 

CHAPTER  XVI. 
Urin.vry  Fever 185 

CHAPTER  XVII. 
Urethral  Instruments:  Their  Care  and  Use        ....     188 

CHAPTER  XVIII. 
Common  Affections  of  the  Glans  and  Prepuce  ....     198 

CHAPTER  XIX. 
The  Chancroid 208 

CHAPTER  XX. 
Syphilis 221 

CHAPTER  XXI. 
The  Initial  Lesion 228 

CHAPTER  XXII. 
The  Secondary  Period 236 

CHAPTER  XXIII. 
Syphilis  of  the  Appendages  of  the  Skin 263 


CONTENTS  vii 

CHAPTER  XXIV. 

Syphilis  of  the  Mucous  Membranes 2f)7 

CHAPTER  XXV. 
Syphilis  of  the  Digestive  Organs 200 

CHAPTER  XXVI. 

Syphilis  of  the  Respiratory  Organs 278 

CHAPTER  XXVII. 

Sy'philis  of  the  Organs  of  Circulation 282 

CHAPTER  XXVIII. 
Syphilis  of  the  Genito-urinary  Organs 284 

CHAPTER  XXIX. 

Syphilis  of  the  Nervous  System 288 

CHAPTER  XXX. 

Syphilis  of  the  Muscles 296 

CHAPTER  XXXI. 
Syphilis  of  the  Bones,  Cartilages,  and  Joints    ....     301 

CHAPTER  XXXII. 

Syphilis  of  the  Ey^e 306 

CHAPTER  XXXIII. 

Syphilis  of  the  Ear 314 

CHAPTER  XXXIV. 
Constitutional  Treatment  of  Syphilis 316 

CHAPTER  XXXV. 

Hereditary  Syphilis 336 

CHAPTER  XXXVI. 
Lesions  of  Hereditary  Syphilis 339 


VENEREAL  DISEASES. 


CHAPTER  I. 
GONORRHEA. 

INTRODUCTION. 

Gonorrhea,  or  specific  urethritis,  is  a  virulent,  infectious, 
and  suppurative  process,  attacking  most  frequently  the 
mucous  membrane  of  the  urethra  and  the  glandular  struct- 
ures in  anatomical  relation  with  it.  Gonorrheal  ophthalmia, 
or  proctitis,  may  occur  during  the  course  of  a  urethral  gonor- 
rhea, the  organism  having  been  deposited  upon  one  of 
these  structures  either  as  the  result  of  accident  or  of  un- 
natural practises  in  depraved  individuals.  Ophthalmia,  or 
proctitis,  may  also  be  observed  independently  of  urethral 
infection  in  the  bearer. 

Cases  of  gonorrheal  stomatitis  and  rhinitis  have  been 
reported,  but  as  yet  lack  positive  and  sufficient  proof,  and 
therefore  cannot  be  accepted  without  much  reserve. 

Specific  urethritis  is  the  most  common  of  all  the  \enereal 
diseases,  is  usually  sexual  in  origin,  and  occurs  with  the 
greatest  frequency  between  the  twentieth  and  thirtieth 
years,  although  cases  of  gonorrheal  infection  are  not  infre- 
quently encountered  in  infants  and  young  children,  and  the 
2 


18  GONORRHEA 

disease  is  also  mot  witli  in  middle-aged,  and  e\en  elderly 
individuals. 

An  attaek  of  gonorrhea  confers  no  immunity  upon  its 
bearer,  reinfection  being  followed  by  a  reappearance  of  the 
disease  with  all  of  its  symptoms  often  quite  as  severe  as 
those  of  the  initial  or  previous  attack. 

As  a  rule,  the  intervening  inUd  attacks  are,  in  reality, 
nothing  more  than  a  lighting  up  of  an  imcured  and 
localized  gonorrheal  process,  either  in  the  in-ethra  itself  or 
in  some  of  the  glandular  structures  in  relation  with  it; 
the  exciting  causes  being  alcoholic,  dietary,  and  sexual 
excesses,  non-specific  secretions  from  the  female  genitalia, 
concentrated  urine,  rough  instrumentation,  irritating  in- 
jections, violent  physical  exertion,  or  in  fact,  anything  that 
in  any  way  causes  irritation  and  congestion  of  the  urethra 
or  its  contiguous  structures. 

Infection  with  the  gonococcus  may  be  cither  direct  or 
mediate. 

Direct  infection  consists  in  the  transference  of  gonorrheal 
pus  from  the  genitalia  of  one  person  to  those  of  another 
during  coition.  This  is  the  usual  and  most  common  mode  of 
infection,  although  it  may  also  result  from  unnatural  sexual 
practises. 

Mediate  infection  may  occur  when  instruments,  syringes, 
towels,  dressings,  the  fingers,  or  in  fact,  any  articles  that 
have  been  contaminated  with  gonorrheal  pus  are  brought 
into  contact  with  the  meatus  or  urethral  mucous  membrane. 
While  this  method  of  infection  is  certainly  rare,  we  should 
not  be  so  dogmatic  and  skeptical  as  to  deny  its  possibility. 
The  author  has  seen  a  number  of  cases  which  permitted  no 
doubts  as  to  the  disease  having  been  acquired  in  this  inno- 
cent manner. 


INTROD(/CTION  19 

Etiology. — The  exciting  cause  o!'  tlic  (lisc;is(;  is  a  specific 
(lil)Ioeoccus  discovered  by  Neisser  ;unl  luimcd  hy  liim  the 
gonocoeciis. 

This  organism  is  the  exciting  cause  of  every  case  of 
gonorrhea  (specific  urethritis).  Cases  of  urethritis  are  ncjt 
uncommonly  encountered,  however,  in  which  the  gonococcus 
cannot  be  found.  These  infections  are  spoken  of  as  non- 
specific or  simple  catarrhal,  the  suppuration  being  due 
to  other  microorganisms. 

The  physician  should  therefore  exercise  the  greatest 
care  and  common-sense  in  every  case  before  giving  a  final 
and  positive  opinion  as  to  its  nature,  as  on  his  word  may 
rest  the  honor  and  loj'alty  of  wife,  husband,  or  consort. 

The  gonococci  are  D-shaped  organisms,  measuring  from 
0.8  to  1.6  mmm.  in  length  and  from  O.G  to  0.8  mmm.  in 
breadth.  As  seen  under  the  microscope  they  occur  in  pairs, 
with  the  flat  or  inner  borders  in  apposition,  like  the  two 
halves  of  a  coffee  bean  (Fig.  1).  They  multiply  very  rapidly 
under  favorable  circumstances,  each  pair  splitting  into  four 
by  means  of  cleavage  at  right  angles  to  the  median  fissure. 

In  gonorrheal  pus  they  occur  within  and  upon  the  phago- 
cytes and  epithelial  cells  and  scattered  about  between  them, 
grouped  in  twos,  fours,  eights,  etc.,  and  never  arranged  in 
definite  chains. 

They  are  readily  found  and  recognized  in  the  urethral 
pus  of  acute  cases;  but  with  increasing  difficulty  as  the 
gonorrheal  process  becomes  subacute  and  chronic,  when 
it  is  then  most  difficult,  and  sometimes  impossible,  to  dif- 
ferentiate them  from  other  diplococci,  except  by  culture 
experiments,  which  should  always  be  employed  in  doubtful 
cases  before  giving  a  final  and  positive  opinion  as  to  the 
nature  of  a  given  diplococcus. 


20  GONORRHEA 

In  luakiiiu-  a  diagnosis  by  microscopic  examination  only 
those  organisms  which  arc  hiintccUidur  slionid  i)o  considered. 

The  method  of  oKtaining  and  staining  the  smear  should 
be  as  follows: 

The  entire  glans  penis  and  ])reputial  ea\ity  should  be 
thoroughly  cleansed,  and  the  j)ns  at  the  meatus  squeezed 


Fig.  1. — Gonococci  in  the  acute  or  suppurative  stage.      (OriKinal.) 

out  and  wiped  off  with  sterile  gauze.  A  sterilized  platinum 
loop  is  then  passed  into  the  lu-ethra  to  obtain  the  secretion 
for  examination,  or  a  droj)  of  pus  expressed  from  the  meatus; 
this  is  spread  in  a  very  thin  him  on  a  clean  glass  slide  or 
cover-glass,  allowed  to  dry  in  the  air,  and  is  then  passed 
through  the  flame  of  an  alcohol  lamp  or  Bunsen  })urner  two 


INTIIODUCTION  21 

or  three  times,  l)eiii<;-  ciircl'iil  to  Iuiac  llie  pus  siilc  uppciinost. 
A  few  drops  of  a  1  ])cr  cent,  watery  solulion  of  itietliylene 
blue  are  then  a])j)lied,  left  on  for  a  miinite,  and  then  WMslied 
off  with  distilled  water  and  the  jm-paration  (h-ied.  The 
specimen  can  now  be  examined  by  means  of  ;i  oiic-lwiH'lh 
inch  oil-immersion  lens,  when  all  of  the  orfi;anisnis  in  the 
field  will  be  seen  to  have  taken  on  a  deep  blue  c(jlor.  Should 
intracellular  organisms  of  the  type  described  above  be 
found,  a  second  smear  should  be  ol)tained  and  stained  l>y 
Gram's  method,  as  follows: 

The  specimen  having  been  fixed  as  before,  l)y  fhiniing,  is 
stained  for  two  minutes  with  either  carbol-  or  anilin-water 
gentian  violet;  this  is  then  drained  off  and  the  smear  flooded 
with  Gram's  iodin  solution  for  one  minute.  The  specimen 
is  then  decolorized  in  alcohol,  washed  with  distilled  water, 
and  counter-stained  with  1  per  cent,  watery  Bismarck-brown 
solution. 

If  the  intracellular  diplococci  in  this  smear  ha^'e  given 
up  the  gentian  violet  and  are  stained  brown  we  can  then 
be  reasonably  certain  that  they  are  gonococci,  but  the  fact 
should  never  be  forgotten  that  when  the  organisms  occur 
only  very  scantily,  or  when  any  other  cause  for  doubt 
exists,  a  final  diagnosis  should  never  be  made  without  the 
assistance  of  cultures.  Other  diplococci  have  been  found 
in  the  normal  urethra  which  bear  so  striking  a  resemblance 
to  gonococci  as  to  general  appearance  and  color  reactions 
that  in  some  instances  they  can  only  be  differentiated  by 
culture  experiments;  and  as  these  latter  are  beyond  the 
reach  of  many  physicians,  we  cannot  be  too  careful  and 
conservative  in  giving  an  absolute  and  positive  opinion  as 
to  the  specific  nature  of  a  gi\-en  diplococcus. 

For  other  methods  of  staining,  and  for  culture  and  in- 


22      ,  GONORRHEA 

noculation  exix'rinu'iits  witJi  the  gonococcus,  tlic  reader 
is  referred  to  any  of  the  standard  works  on  bacteriology. 

Pathology. — When  infection  of  the  nretln'a  by  tlie  gono- 
coccns  occurs  the  invasion  of  the  tissues  proceeds  as  follows: 
The  gonococci,  having  been  deposited  on  the  superficial 
layer  of  the  lips  of  the  meatus  or  of  the  fossa  navicularis, 
increase  rapidly  in  numbers  and  give  rise  to  a  scanty,  serous 
discharge,  which  appears  at  the  meatus  and  which  consists 
of  serum  and  epithelial  cells,  u])on  and  between  which 
gont)cocci  are  seen  in  ^•arying  numbers.  This  constitutes 
the  first,  prodromal,  or  serouft  stage  of  the  disease. 

The  organisms  spread  more  or  less  rapidl\'  along  the 
urethra  by  continuity  of  tissue,  and  at  the  end  of  twelve 
to  twenty-four  hours  ])enetrate  the  cement  substance 
between  the  epithelial  cells  and  pass  into  the  subepithelial 
connective-tissue  layer  and  the  blood^'essels. 

This  stage  of  invasion  is  marked  by  the  onset  of  a  ])rofuse, 
purulent  discharge  and  the  destruction  and  casting-olf  of 
the  normal  cylindrical  epithelium  of  the  urethra,  thus  giving 
free  access  to  further  gonococcus  invasion,  and  marking 
the  onset  of  the  second,  acute,  or  ■imrident  stage.  The  puru- 
lent discharge  is  made  up  of  pus  and  epithelial  cells,  serum, 
and  sometimes  a  few  red  blood  cells;  the  gonococci  being 
found  principally  in  the  pus  cells,  although  some  free  groups 
may  be  seen. 

After  a  period  varying  between  ten  days  to  two  weeks 
the  character  of  the  discharge  begins  to  change.  It  is  less 
profuse,  and  from  being  thick  and  creamy  becomes  muco- 
purulent and  sticky.  At  the  same  time  the  other  signs  of 
acute  inflammation  begin  to  abate,  and  the  disease  enters 
upon  the  third,  subacute,  or  declining  stage.  The  conges- 
tion and  edema  of  the  mucous  membrane  diminish  from 


INTIIOIXJCTION  23 

(I;iy  to  (lay,  llic  (liscliar<;(:  hcromin^r  corrcsiMHidiii^ly  tliiiiiHT 
and  scantier  until  tlu;  fourth  or  chronic  stage  is  rcadiffl, 
which  is  marked  by  a  sliglit  mucoid  or  serous  disdiarj^'c, 
often  visible  only  in  the  morning,  vvitii  a  mucous  membrane 
wliich  is  normal  except  for  isolated  spots  of  c-ongestion, 
erosion  or  sui)erficial  ulceration,  these  marking  the  localities 
where  the  gonorrlieal  process  has  become  localized.  Such 
areas  are  most  commonly  found  in  the  bulbous  portion 
of  the  canal,  whlcli,  being  of  larger  caliber,  surrouiuleil  by 
erectile  tissue,  and  from  its  dei)endent  position,  jxtorly 
drained,  is  particularly  prone  to  harbor  a  chronic  inflam- 
matory process. 


CHAPTER    IT. 
ACUTE  GONORRHEA. 

Acute  gonorrhea  is  spoken  of  as  })ein<2;  either  anterior 
or  posterior,  aeeording  to  the  portion  of  the  uretJira  involved 
by  the  infiannnatory  ])rocess. 

If  the  disease  be  situated  in  the  anterior  urethra — that  is, 
between  tlie  meatus  lu'inarius  externus  and  the  anterior 
layer  of  the  triangular  ligament  (pendulous  and  bulbous 
urethrse) — it  is  ealled  anterior  gonorrhea;  but  if  in  the 
posterior  urethra,  which  includes  that  portion  of  the  canal 
situated  between  the  anterior  layer  of  the  triangular  liga- 
ment and  the  bladder  (membranous  and  prostatic  urethrse), 
it  is  called  posterior  gonorrhea. 

^Vhen  the  entire  length  of  the  urethra  is  involved,  as  is 
usually  the  case,  we  then  speak  of  it  as  an  anteroposterior 
gonorrhea;  and  if  the  disease  has  extended  into  the  bladder, 
in\()l\ing  to  a  limited  extent  the  mucous  membrane  sur- 
rounding the  vesical  orifice  and  trigone,  it  is  known  as  a 
uvctln-ocystitis. 

ACUTE  ANTERIOR  GONORRHEA. 

After  a  period  of  incubation  varying,  in  the  majority'  of 
cases,  from  two  to  seven  days,  the  symptoms  of  acute 
anterior  gonorrhea  make  themselves  manifest. 

For  clinical  purposes  the  course  of  the  disease  is  best 
di\ided  into  four  stages,  as  follows:  the  prodromal  stage, 
the  acute  stage,  the  stage  of  decline,  and  the  chronic  stage. 


ACUTE   ANTl'naOU  aONORRIl/'JA  2.) 

Ill  the  prodi'oiiiiil,  or  first  stiii^^c,  wliicli  iii;iy  last  from  ii 
few  lioiirs  to  ii  (liiy  or  two,  the  synii)toiiis  iiia\'  he  (jiiitc 
severe,  or  so  mild  as  often  to  escape  notice.  TJiey  consist 
of  pricking  or  tickliii}^  sensations  in  tli(;  meatus,  which 
becomes  reddened,  slightly  swollen  and  glued  together,  or 
filled  witli  a  scanty,  serous  sec;retion.  Sometimes  decided 
pain  is  felt  in  tlie  glans,  but  in  otJier  cases  jiain  is  only 
experienced  during  and  after  urination. 

At  the  end  of  a  day  or  two  all  of  the  abov^e  symjjtoms 
become  more  marked.  The  meatus  is  pouting  in  appearance 
and  surrounded  by  a  zone  of  redness,  the  secretion  is  increased 
in  amount  and  assumes  a  decidedly  i)urulcnt  character,  the 
pain  is  sharper  and  during  urination  gives  rise  to  a  decided 
burning  sensation  in  the  urethra,  which  is  spoken  of  as 
ardor  urintc;  this  may  be  continuous,  or  only  felt  during 
and  after  the  act. 

With  the  onset  of  the  second  or  acute  stage,  which  usually 
begins  at  the  end  of  twent^'-four  to  forty-eight  hours,  the 
discharge  becomes  profuse,  greenish-yellow  in  color,  creamy 
in  consistence,  and  sometimes  tinged  with  blood,  the  lips 
of  the  meatus  and  often  the  entire  glans  penis  are  bright 
red  in  color,  hot  and  swollen;  the  edema  may  extend  from 
the  lower  angle  of  the  meatus  into  the  frenum  and  thence 
into  the  prepuce,  in  this  way  being  liable  to  produce  either  a 
phimosis  or  paraphimosis,  according  to  the  conformation 
of  the  parts. 

In  se\'ere  cases  the  lymphatics  on  the  dorsum  of  the 
penis  become  swollen  and  painful,  and  as  they  communicate 
with  the  inguinal  lymph  ganglia  these  latter  may  become 
enlarged  and  tender;  but  they  very  rarely  suppurate.  As 
the  gonorrheal  process  extends  up  the  urethra  it  sometimes 
causes  an  inflammation  of  one  or  more  of  the  periurethral 


^6  ACUTE  GONORRHEA 

t'olliclcs.  which  can  he  felt  beneatli  tlie  skin  as  small  shot- 
like  botlies.  In  severe  cases  the  corpus  spongiosum  becomes 
hard  and  i)ainfu],  and  it'  this  condition  extends  to  the  bulbous 
portion,  patients  experience  great  pain  in  sitting  down  and 
crossing  the  legs,  as  pressure  is  thereby  brought  directly 
on  this  swollen  and  inflamed  mass  of  erectile  tissue.  Every 
act  of  urination  is  now  accompanied  by  intiMise  suffering 
as  the  acid  urine  forces  its  way  through  the  urethra,  whose 
caliber  has  been  greatly  lessened  by  the  edema  of  its  mucous 
membrane,  from  whose  congested  surface  blood  is  some- 
times forced  by  the  pressure  of  the  accelerator  urinse  muscle 
on  the  erectile  tissue  of  the  bulb  at  the  close  of  urination. 
The  stream  assumes  \'arious  shapes  and  sizes,  and  in  severe 
cases  comes  only  in  drops,  or  there  may  be  complete  reten- 
tion of  urine,  due  to  swelling  of  the  mucous  membrane  and 
compressor  spasm. 

Painful  erections,  and  in  some  cases,  chordee  now  come  on, 
especially  at  night,  which  rob  the  patient  of  his  rest,  and 
in  this  way  cause  debility  and  general  malaise  from  loss  of 
sleep,  and  nervousness.  True  chordee  is  due  to  infiltration 
of  the  meshes  of  the  corpus  spongiosum  with  inflammatory 
material,  which  prevents  its  full  extension  when  the  corpora 
cavernosa  become  erect,  thus  causing  the  penis  to  curve 
do^^^lward.  It  is  a  rare  complication  of  acute  gonorrhea, 
as  compared  to  painful  erections,  which  occur  in  almost 
every  case. 

The  third  or  declining  stage  usually  begins  at  about  the 
end  of  the  second  or  beginning  of  the  third  week  and  is  marked 
by  a  general  improvement  in  the  patient's  condition.  Urina- 
tion becomes  less  painful,  the  erections  at  night  disappear, 
as  do  also  the  swelling  and  soreness  along  the  corpus  spon- 
giosum. The  meatus  and  glans  penis  begin  to  assume  their 
normal    appearance,    and    the    discharge    becomes    muco- 


ACUTE  POSTERIOR  GONORRHEA  27 

purulent,  tJiiiiiicr  jiihI  stickier  in  cliJiracter,  until  it  is  so 
slight  in  junount  as  to  cause  only  a  gluing  of  the  lips  of  the 
meatus  iu  tJie  morning,  from  wJiich,  when  sc^parated,  a  few- 
drops  of  secretion  may  be  pressed.  The  further  vuicorn- 
plieated  course  of  the  disease  is  indistinguishahic  from  that 
of  chronic  gonorrhea,  and  will  he  descrihcd  nndcr  lli;it  head- 
ing in  Chapter  VI. 

Relapses  may  occur  at  any  time,  as  the  patient,  thinking 
himself  about  cured,  is  apt  to  indulge  in  overexercise, 
alcoholics,  indiscretions  in  diet,  or  sexual  intercourse,  which 
indulgence  is  rapidly  followed  by  the  return  of  many  or  all 
of  the  acute  inflammatory  symptoms  described  above. 

ACUTE  POSTERIOR  GONORRHEA. 

When  the  gonorrheal  process  passes  beyond  the  anterior 
layer  of  the  triangular  ligament  and  involves  the  mem- 
branous and  prostatic  portions  of  the  canal  (posterior 
urethra),  we  speak  of  it  as  an  acute  posterior  gonorrhea. 
In  from  90  to  100  per  cent,  of  all  cases  of  acute  gonorrhea 
the  disease  passes,  quite  rapidly,  up  the  urethra  to  the 
bulb  and  thence  into  the  posterior  portion.  Posterior 
urethritis,  therefore,  mstead  of  being  a  complication,  is 
in  reality  part  of  the  usual  course  of  the  disease  in  the 
vast  majority  of  cases. 

This  invasion  of  the  deeper  parts  of  the  canal  may  take 
place  so  gradually  and  with  such  mild  symptoms  as  to 
escape  detection,  unless  we  are  on  the  lookout  for  it;  but 
in  the  majority  of  cases  it  is  indicated  by  a  sudden  and  very 
marked  decrease  in  the  amount  of  discharge  at  the  meatus, 
accompanied  by  an  increased  frequency  in  urination,  with 
inability  to  hold  the  urine  when  the  desire  comes  on  (urgency) , 
followed  bv  vesical  tenesmus,  and  in  severe  cases  hx  blood 


::^8  ACUTE  GONORRHEA 

ill  the  urine  at  the  end  of  niieturitidii  (terminal  heinaturia), 
wJiieh  comes  from  the  eoiiiiested  vessels  of  tlie  i)rostatic 
urotJira,  whicli  are  ruptured  by  the  spasmodic  contractions 
of  the  prostatic  muscuhir  fibres,  at  the  close  of  urination. 
In  sueli  cases  small,  worm-like  clots  of  blood,  formed  in  the 
urethra  during  the  intervals  of  voiding,  are  sometimes 
passed  with  the  first  gush  of  urine  as  it  washes  out  the 
contents  of  the  canal. 

In  some  cases  the  patient  has  to  urinate  every  few  minutes, 
each  act  being  followed  by  a  few  drops  of  blood  and  intense 
pain  in  the  glans  penis,  perineum,  and  rectum;  in  others 
there  is  temporary  incontinence  of  urine,  due  to  the  extreme 
irritability  of  the  prostatic  mucous  membrane,  so  that  when 
the  patient  goes  to  sleep  at  night,  painful  pollutions  occur 
that  are  sometimes  blood-stained.  Retention  of  urine  may 
occur  at  any  time  from  spasm  of  the  compressor  urethrse 
m-uscle  brought  on  by  the  intense  local  irritation;  we  should 
therefore  always  be  prei)ared  to  deal  promptly  with  this 
distressing  complication. 

Vesical  tenesmus,  if  severe,  is  often  accompanied  by  a 
temporary  albuminuria,  which  disappears  as  the  tenesmus 
subsides. 

In  the  mild  cases  our  only  way  of  detecting  an  involve- 
ment of  the  posterior  urethra  is  by  the  frequent  employment 
of  Thompson's  two-glass  test,  which  is  performed  in  the  follow- 
ing manner: 

The  patient  passes  the  greater  part  of  his  urine  into 
one  glass  cylinder  and  the  remainder  into  another.  If 
the  disease  is  confined  to  the  anterior  urethra,  the  urine  in 
the  first  glass  will  be  cloudy,  from  the  pus  washed  out  of  the 
anterior  urethra,  while  that  in  the  second  cylinder  will  be 
clear,  as  it  consists  of  normal  urine  from  tlie  bladder  passed 
through  a  now  clean  urethra.    Should  the  posterior  urethra 


ACUTE  POSTERIOR  GONORRHEA 


29 


be  involved,  Jiowcvcr,  tlie  pus  I'roiii  it,  escaping  backward 
into  the  bladder,  renders  all  tin;  urine  in  lliut  viscus  cloudy; 
the  urine  in  both  eylind(>rs  therefore'  will  be  purulent 
and  opaque,  tlie  first  a,  trifle  more  so  than  the  second,  as  it 
consists  of  turbid  urine  from  tJie  bliidder  ])lus  the  urethral 
secretion  wfiieh  it  washes  out. 

For  tlie  proj)er  performance  of  tJiis  test  it  is  essential 
that  the  patient  have  at  least  8  to  ]()  ounces  of  urine  in 
the  bladder,  a  well-marked  urethral  discharge,  an(f  that  fie 
should  pass  the  larger  part  of  his  bladder  contents  into  the 
first  glass.  Under  these  conditions  the  test  is  of  great 
diagnostic  value  in  acute  cases,  but  it  is  quite  useless  in 
subacute  or  chronic  ones. 

As  tlie  opacity  in  a  given  urine  is  not  always  due  to  the 
presence  of  pus  (pyuria),  the  following  table  of  Ultzmann 
renders  this  subject  clear  in  a  very  concise  manner.  By 
gradually  lieating  the  upper  lialf  of  tlie  urine  (in  a  test-tube) 
to  boiling,  the  opacity: 


Vanishes. 

Increases. 

Remains  un- 
changed even 
after  addition 
of   acetic    acid. 

If      due 
to  acid 
urates. 

If    due    to    earthy   jihosphatcs, 
pus  corpuscles. 

Add  one  or  two  drops  of  acetic 

carbonates, 
acid. 

or 

The  dimming 
is  caused  by 
catarrhal  secre- 
tion, or  by  bac- 
teria. 

Dimness  van- 
ishes      with 
evolution  of 

Dimness  van- 
ishes without 
evolution    of 

Dimness   re- 
mains   un- 
changed : 

gas: 
Carbonates. 
(Carbonaturia.) 

gas: 
Phosphates. 
(Phosphaturia.) 

Pus. 
(Pyuria.) 

1 

30  ACUTE  GONORRHEA 

The  duration  of  the  attack  depends  hir[>;ely  ujjoii  the 
treatment  employed  and  the  habits  of  the  patient. 

Acute  posterior  gonorrhea  is  apt  to  be  very  severe  and 
rebelhous  to  treatment  in  ])ersons  who  have  a  previously 
congested  condition  of  the  deej)  uretlu'a,  prostate,  or  seminal 
vesicles,  either  as  the  result  of  sexual  abnormalities  or  ex- 
cesses, or  a  previous  gonorrheal  infection  of  these  structures. 

Diagnosis. — The  diagnosis  of  acute  gonorrhea  is,  as  a 
rule,  readily  made  from  the  history  of  the  case,  the  purulent 
urethral  discharge,  which  should  always  be  examined 
microscopically  for  the  gonococcus,  the  redness  and  swelling 
of  the  meatus  and  glans,  painful  urination,  and  the  period 
of  incubation. 

There  are  cases,  however,  in  which  it  must  be  difl'erentiated 
from  balanitis,  balanoposthitis,  chancre  of  the  meatus  or 
urethra,  and  chancroids  of  the  meatus. 

In  balanitis  or  balanoposthitis,  if  the  ])repuce  can  be 
retracted  far  enough  to  expose  the  meatus,  the  parts  should 
be  carefully  wiped  off  and  examined,  when  a  correct  diagnosis 
can  easily  be  made,  as  the  pus  will  be  seen  to  exude,  either 
from  the  meatus  if  it  be  gonorrhea,  or  from  between  the 
prepuce  and  glans  if  it  be  balanitis  or  balanoposthitis. 

Chancre  of  the  meatus  or  within  the  urethra  gives  rise  to 
a  slight  watery,  mucous,  or  mucopurulent  discharge,  with 
induration  of  the  lesion  and  of  the  inguinal  lymphatic  glands 
at  the  end  of  about  ten  days.  Endoscopic  examination  will 
reveal  the  lesion  if  it  be  situated  in  the  canal.  As  the  indura- 
tion about  the  lesion  develops,  there  is  increasing  difficulty 
in  urination.  ^Microscopic,  dark-field  examination  of  the 
discharge  will  exclude  the  gonococcus  and  may  reveal  tlie 
presence  of  the  Spirocheta  pallida. 

Chancroids  of    the    meatus  cause  a  purulent  discharge 


ACUTE  POSTERIOR  GONORRHEA  31 

which  is  auto-iriocuhible.  Tlicy  may  ffivc  rise  to  soino 
inflammatory  thickening  of  the  surrounding  tissues,  but 
never  to  true  inchu'ation.  The  inguinal  glands  are  more  or 
less  painful  and  enlarged,  and  may  even  go  on  to  suppuration 
and  abscess  formation. 

Prognosis. — The  prognosis  of  gonorrliea  is,  as  a  rule, 
good,  provided  the  patient  is  otherwise  healthy  and  is  willing 
to  carry  out  minutely  all  the  details  of  an  intelligent  and 
conservative  treatment  until  he  is  pronounced  cured  by  his 
physician. 

There  are  cases,  however,  in  which  serious  and  sometimes 
even  fatal  complications  occur,  such  as  gonorrheal  synovitis, 
tenosynovitis,  bursitis,  myositis,  arthritis,  peri-  and  endo- 
carditis, peritonitis,  meningitis,  and  pyemia.  We  must 
therefore  explain  to  our  patients  that  gonorrhea  is  at  best 
a  grave,  persistent,  and  far-reaching  infection,  and  that 
treatment  must  not  be  relaxed  until  the  urethra  and  the 
structures  in  anatomical  relation  with  it  have  been  returned 
to  their  normal  condition. 

If  during  the  course  of  a  case  of  acute  posterior  gonorrhea 
a  digital  examination  of  the  prostate  gland  is  made  by  rectum, 
it  will  frequently  be  found  swollen,  hot,  throbbing,  and 
exquisitely  tender  (acute  prostatitis).  Occasionally  one 
or  even  both  of  the  seminal  vesicles  may  be  involved,  but 
this  complication  is  rare  in  comparison  with  prostatitis,  as 
has  been  demonstrated  by  a  large  number  of  examinations 
made  by  the  author  during  the  acute  stage  of  the  disease. 


CHAPTER   III. 

TREATMENT  OF  ACUTE  ANTERIOR  AND 
POSTERIOR  GONORRHEA. 

The  treatment  of  acute  anterior  gonorrliea  (l('])eii(ls 
entirely  upon  the  stage  of  the  disease  at  \vhieli  the  ])atient 
presents  himself  to  the  physician. 

If  in  the  prepurulent  or  serous  stage,  some  form  of  aborti\-e 
treatment  may  be  employed.  If,  however,  the  disease 
has  reached  the  i)urulent  stage,  then  a  milder  and  more 
sympt(Mnatic  ])laii  should  })e  instituted. 

Abortive  Treatment. — The  abortive  treatment  of  acute 
gonorrhea  or  specific  urethritis  should  only  be  employed 
during  the  first  day  or  so  of  the  disease,  while  the  diseluirge 
is  still  serous  in  character,  and  shows  under  the  microscope 
only  epithelial  cells  and  gonococci,  but  no  pus  cells,  as  in 
this  stage  the  gonococci  are  situated  upon  the  epithelium 
of  the  urethra  and  are  therefore  in  a  ])osition  to  be  destroj'ed 
by  local  applications. 

Unfortunately  the  vast  majority  of  ])atients  do  not 
present  themselves  until  the  discharge  has  become  purulent, 
when  it  is  too  late  to  try  any  form  of  abortive  treatment, 
as  by  that  time  the  gonococci  have  penetrated  the  epithelial 
layer  of  the  urethral  mucous  membrane  and  arc  therefore 
to  a  great  extent  beyond  our  reach.  It  can  readily  be  seen, 
therefore,  that  but  few  patients  will  seek  medical  advice 
early  enough  to  justify  our  attempting  to  abort  the  disease. 


A  HO  irn  VK  TiacA  tmhn  t 


33 


However,  if  after  a  ciircriil  inicroscopie  s1ii(l\'  of  1  lie  di-^cluirjfr-, 
the  abortive  treatment  has  been  decided  upon,  the  put  lent 
should  always  be  informed  that  it  is  more  or  less  pninlul,  apt 
to  fail,  and  may  lead  to  such  {•otii])lieatioiis  as  periurethral 
abscess,. posterior  urethritis,  ei)ididyiiiitis,  ])rostatitis,  seminal 
vesiculitis,  abscess  of  tJie  i)rostate,  and  cystitis. 

The  steps  in  the  })rocedure  are  as  follows:  Tiic  patient 
having  voided  his  urine,  thus  washing  out  any  accumulated 
secretion,  lies  down.  The  meatus  and  glans  i)enis  are 
washed  with  sterile  water  and  a  small  (10  to  12  French) 


Fig.  2. — Author's  four-ounce  bladder  syringe  and  coupler. 


soft-rubber  catheter  is  passed  into  the  urethra  for  two  or 
three  inches,  the  patient  compressing  the  canal  firmly 
behind  this  point  to  prevent  the  backward  passage  of  fluids. 
Through  the  catheter  by  means  of  a  four-ounce  hand  syringe 
(Fig.  2),  the  canal  is  irrigated  with  warm,  sterile  water, 
thrown  in  slowly  and  gently,  the  solution  running  from  be- 
hind forward,  alongside  the  catheter  and  escaping  at  the 
meatus.  After  this  thorough  irrigation  of  the  canal  the 
catheter  is  very  slowly  withdrawn  while  we  inject  through 
it,  with  an  instillation  syringe  (Fig.  3),  a  drachm  or  two  of  a 
solution  of  nitrate  of  silver,  10  to  15  grains  to  the  ounce. 
3 


34     ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHEA 

The  fossa  navicularis  and  adjacent  portions  of  the  urethra, 
which  are  the  seat  of  tlie  disease  at  this  period,  are  thus 
thoroughly  medicated  with  the  silver  solution,  and  the 
gonococci,  situated  upon  the  surface  of  the  mucous  mem- 
brane, are  destroyed. 

If  so  desired,  we  may  substitute  for  the  nitrate  of  silver 
solution  a  10  or  even  20  per  cent,  solution  of  protargol, 
which  is  almost  as  efficacious  and  not  so  irritating.  Argyrol 
and  the  various  other  so-called  "organic"  silver  preparations 
have  not  proved  as  efficient  in  the  author's  experience. 


Fig.  3. — Author's  instillation  sj'ringe. 

The  patient  is  now  instructed  to  rest  as  much  as  possible, 
put  upon  a  light,  non-irritating  diet,  both  as  to  solids  and 
liquids,  and  the  urine  rendered  bland  by  still  waters  and 
alkaline  mixtures.  The  bowels  are  moved  freely  by  means 
of  cathartic  pills,  and  the  penis  and  preputial  cavity  kept 
clean  by  frequent  immersions  in  hot  lead-water  or  hot 
bichloride  solution,  1  to  5000.  The  silver  application  is 
followed  in  a  short  time  by  painful  urination  and  a  purulent 
discharge,  which,  if  the  treatment  be  successful,  subsides 
in  a  few  days,  leaving  the  patient  with  a  slight  muco- 
purulent exudate,  which  is  readily  controlled  by  astringent 
hand  injections.  If,  on  the  other  liand,  the  treatment  has 
failed  to  abort  the  disease,  then  the  discharge  continues, 
showing  under  the  microscope  gonococci  and  pus  cells  in 


ABORTIVE   TREATMENT  35 

increasiiifi;  iiiiiiihci-s,  tJic  case  now  presenting  llie  flinifal 
])i('tiiro  of  tlic  acute  or  sup])urative  stage,  in  wliieli  e\cnt 
all  further  attempts  at  abortive  treatment  siicjuld  he  ahan- 
doned. 

It  should  not  be  forgotten  that  this  procedure  is  exceedingly 
irritating,  and  should  never  be  resorted  to  if  there  is  the 
slightest  indication  of  the  discharge  having  become  purulent. 
Cases  have  been  reported  in  which  the  use  of  this  method, 
after  the  onset  of  the  purulent  stage,  has  resulted  in  more  or 
less  sloughing  of  the  mucous  membrane  of  the  anterior 
urethra. 

The  Janet  method  of  aborting  and  treating  acute  gonorrhea 
has  been  much  in  vogue,  but  its  popularity  at  the  present 
writing  seems  to  be  decidedly  on  the  wane.  Its  advocates 
claim  that  it  will  abort  the  disease  in  its  incipient  stage,  and 
cut  short  the  period  of  acute  suppuration  if  employed  at 
a  later  date.  Ten  or  twelve  treatments  are  said  to  be  suf- 
ficient to  accomplish  a  cure.  Warm  solutions  of  perman- 
ganate of  potash  are  used  for  the  irrigations,  and  vary  in 
strength  from  1  to  4000  to  1  to  1000,  and  even  up  to  1  to  500 
during  the  declining  stage. 

Janet  uses  an  irrigator  or  fountain  syringe  with  several 
feet  of  rubber  tubing,  to  which  is  attached  a  conical  glass 
nozzle;  a  stopcock  on  the  tubing  controls  the  flow  of  the 
fluid.  The  patient,  having  urinated,  lies  on  his  back  or 
reclines  in  a  chair,  and  the  glass  nozzle  is  inserted  snugly 
into  the  meatus  and  the  fluid  turned  on.  The  irrigator  is 
raised  two  feet  above  the  level  of  the  patient  if  the  anterior 
urethra  alone  is  to  be  treated,  but  if  the  posterior  uretlira 
and  bladder  are  to  be  medicated,  it  is  elevated  about  five 
feet  or  even  higher,  so  as  to  increase  the  pressure  and  force 
of  the  flow,  which  in  a  few  minutes  tires  out  and  overcomes 


36     ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHEA 

the  compressor  urethra'  muscli'  and  \  (>si(al  sphincter,  which, 
rehixinjj,  allow  the  solution  to  enter  tlie  deep  urethra  and 
bladder;  when  the  bladder  is  distended,  the  irrigation  is 
stopped,  and  the  j)atient,  standing,  voids  the  solution  by 
the  urethra.  These  irrigations  iwv  given  onee  or  twice  daily, 
one  pint  being  used  for  the  anterior  nretJn"a  and  two  i)ints 
when  the  posterior  urethra  and  bladder  are  to  be  medicated. 
Although  this  method  does  cause  a  rapid  cessation  of  tlie 
purulent  discharge,  as  is  claimed  by  its  advocates,  it  is 
liable  to  cause  more  or  less  dilatation  of  the  glandular  struct- 
ures which  open  into  the  urethra,  and  also  to  leave  the  canal 
in  a  thickened,  congested,  and  irritable  condition,  which 
gives  rise  to  a  watery  or  mucoid  discharge,  very  difficult, 
and  in  some  cases,  almost  impossible  to  cure. 

Spasm  of  the  compressor  muscle,  and  even  of  the  muscular 
layer  of  the  anterior  urethra,  is  frequently  observed  following 
this  treatment;  as  is  also  an  intensely  congested,  hard,  and 
painful  condition  of  the  prostate  gland. 

I  have  seen  a  large  number  of  patients  suffering  from  the 
above  conditions  as  a  result  of  this  treatment,  all  of  them 
informing  me  that  the  method  was  uncleanly  and  painful, 
and  a  few  stating  that  the  irrigations  caused  quite  a  con- 
siderable oozing  of  blood  from  the  meatus. 

The  above  facts  are  not  to  be  wondered  at  when  one 
considers  the  force  and  strength  of  the  solution  rushing 
through  and  distending  such  an  acutely  iiiHanied  and  delicate 
canal  as  the  urethra  is  at  this  time;  also,  the  injurious  effect 
of  overcoming  by  hydraulic  pressure  the  delicate  musculature 
which  guards  the  deep  urethra  and  bladder,  to  say  nothing 
of  the  parts  beyond. 

If  so  desired,  the  bladder  and  urethra  may  be  irrigated 
with  a  small  soft-rubber  catlieter  and  hand  s\'ringe,   and 


TliMATMKNT  OF   Til/']   A(:iITI<:   STAaE  :]7 

most  Siitisl'iictory  results  ohtiiincd  without  fiiiisiii|j;  f  i;iiiiii;i- 
tism  iiiid  iiicrciiscd  coii'^'cstioii  of  llic  imirous  incnihriinc, 
with  injury  to  tlic  {■iit-olV  iiiid  |)n)st<iti(;  inusclcs. 

In  our  cITorts  to  Jiniiiliiliitc  tlic  f^oiiococciis,  we  iimst  never 
forget  that  we  have  a  very  severe  iiidjiinmatory  i)rocess  to 
deal  with,  attacking  one  of  the  most  delicate  and  higiiiy 
sensitive  mucous  membranes  in  the  body,  which,  if  rrnigiily 
or  unskilfully  handled  in  the  acute  stage  of  this  virulent 
process,  will  leave  the  patient's  urethra  and  contiguous 
structures  in  a  more  or  less  permanently  damaged  con- 
dition. 

In  the  vast  majority  of  cases  the  physician  does  not 
see  the  patient  until  the  acute  stage  of  the  disease  is  well 
established  and  it  is  too  late  to  attempt  any  abortive  plan 
of  treatment;  in  which  case  the  only  method  the  author 
can  recommend  is  that  which  is  set  forth  below. 

Treatment  of  the  Acute  Stage. — Patients  must  be  kept 
as  quiet  as  possible,  rest  in  the  recumbent  position  being 
preferable.  For  the  first  week  or  ten  days,  or  even  longer 
if  the  symptoms  of  inflammation  are  very  marked,  the  diet 
should  be  light  and  easily  digested,  and  the  following 
articles  should  be  excluded: 

Ham,  bacon,  red  meats,  green  vegetables,  fresh  fruits  of 
all  kinds,  condiments  and  spices,  vinegar,  coffee,  chocolate, 
cocoa,  all  alcoholic  drinks,  ginger  ale,  and  effervescent  waters. 

Weak  tea  is  allowable  in  moderation,  as  is  smoking. 

The  testicles  must  be  supported  in  a  w^ll-fittmg  suspensory 
bandage  (Figs.  4  and  5),  which  does  not  press  upward  on 
the  urethra  at  the  penoscrotal  junction  or  in  the  perineum, 
and  thus  interfere  with  the  proper,  free  drainage  of  the 
canal.  The  glans  penis  and  the  preputial  cavity  must  be 
kept  scrupulously  clean  by  the  frequent  use  of  hot  water. 


38     ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHEA 

Tlic  penis  should  be  so  dressed  as  to  allow  free  drainage 
of  tlie  uretliral  jius,  wliieli  at  the  same  time  must  be  kept 
from  the  preputial  cavity,  the  patient's  clothing  and  his 
fingers.     These   requirements   are   fulfilled   by   a   piece   of 


Fig.  5 


Figs.  4  and  5. — Suspensory  bandages. 


absurl)ent  gauze  cut  about  four  inches  square  (Fig.  G),  with 
a  slit  in  the  centre  (Fig.  7)  through  which  the  glans  is  passed 
until  the  gauze  rests  in  the  coronal  sulcus  (Fig.  8)  when  the 
prepuce  is  drawn  forward,  carrying  the  gauze  before  and 
beneath  it,  thus  causing  it  to  i)rotrude  beyond  the  preputial 


TliKATMMNT  OF   Tlll<:   AC  (/'I'M   Sl'AGl'J 


:vj 


Fig.  6. — Square  of  absorbent  gauze. 


Fig.  7. — Square  of  absorbent  gauze  with  slit  in  centre. 


41)     ACUTE   AXTElilUh'  A.\D   I'USTERIOR  UOSORRUKA 

orifice  (Fig.  0).  Tliis  (livssiii<2;  slunild  l)i'  cIkih^cmI  several 
times  daily,  accordin^f  to  the  amount  of  discharge.  If  there 
is  much  inflammation  in  the  glans  and  i)rci)uce,  great  relief 
can  be  obtained  by  keeping  the  gauze  moistened  with  lead- 
water.  If  the  prepuce  is  too  short  to  hold  the  above  dressing 
in  place,  the  end  of  the  penis  can  be  j)lacc(l  in  a  bag  of 


Fig.  S. — Gauze  in  coronal  sulfiis. 


absorbent  gauze  wliich  is  j)innc(l  to  the  suspensorj^  bandage 
(Fig.  10).  To  allay  tlic  local  ])ain  and  inflammation,  the 
penis  should  be  immersed  se\eral  times  daily  in  a  liot  lead 
solution,  which  can  be  easily  and  (jnickly  preparcfl  l)y  dis- 
solving one  tablet  in  a  glass  of  hot  water,  each  tablet  con- 
taining 15  grains  of  subacetate  of  lead,  which   is  ccpial  to 


Tim  AT  Ml':  NT   OF    Til /'J    ACUTF   HTACIC 


11 


;i1k)1i(,  I  (Iriicliiii  of  ( ioiiliird's  cxlriict .  Tlic  IidI.  sitz  batli,  at 
a,  t(>ni])('i-atur('  ol"  105'^  to  107°  .1''.,  rclicivcs  to  a  j^rcat  extent 
the  feeliii};'  ol'  soreness  and  stitt'iiess  in  the  j^roins,  jjenis  and 
along  the  hulh,  and  may  he  taken  once  or  twice  diiilx . 


Fig.  9. — Dressing  complete. 


The  bowels  should  be  kept  freely  open,  preferably  by 
cathartic  pills,  as  saline  purgatives  are  apt  to  produce  more 
or  less  urethral  irritation,  owing  to  their  content  of  mag- 
nesium sulphate. 

It  is  extremely  important  to  warn  patients  of  the  danger 
of  infecting  the  eyes,  and  impress  upon  them  the  gravity  of 
such  an  accident;  also  the  danger  of  contammating  water- 


42     ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHEA 

closets,  baths,  towels,  etc.,   and   in  this  way  causing  the 
infection  of  others. 

To  render  the  urine  l)land  and  uon-irritatiui;-,  the  patient 
should  drink  freely  of  any  still  water,  a  glassful  every  hour 


Fig.  10. — Gauze  bag  for  acute  urethriti.s. 

(luring  the  day  and  whenever  he  wakes  at  night.    He  should 
also  be  given  one  of  the  following  alkaline  mixtures: 

I) — Potass,  bicarbonat.,  5J 

Tr.  hyoscyam.,  3ij-iij 

Aq.,  ad      gviij — M. 

Sig. —  5ss  in  water  one  hour  after  each  meal  and  at  midnight. 

I^ — Potass,  acetat.,  5j 

Syr.  anrant.  cort.,  3ij 

Aq.,  ad      gviij— M. 

Sig. — 5ss  in  water  one  hour  after  each  meal  and  at  midnight. 


TItKATMIiNT  OF   Till':   DliCLlNINd  STACK  43 

l\)V  the  prevention  of  i)ainful  erections,  tlie  patient  sJiould 
he  instructed  to  omi)ty  his  l)]a(l(ler  just  before  retiring,  and 
to  sleep  on  Jiis  side  on  a  Jiard  mattress,  with  as  hglit  covering 
as  possible. 

If  awakened  by  an  erection  he  can  usually  o})tjiiii  idicf 
by  emptying  the  bladder  and  by  cold  ai)])lic;itions  to  tlic 
penis;  occasionally,  however,  heat  will  be  found  more 
beneficial. 

Internally,  we  may  prescribe  monobromide  of  camphor, 
potassium  bromide,  lui)ulin,  or  medinal.  If  these  drugs  do 
not  relieve,  we  may  be  compelled  to  resort  to  suppositories 
of  opium,  or  opium  and  belladonna;  but  these  should  never 
be  used  unless  absolutely  necessary,  as  they  may  have  to 
be  continued  for  some  time,  are  constipating,  and  more  or 
less  depressing  in  their  after-effects. 

Treatment  of  the  Declining  Stage. — When  as  a  result  of 
the  above  treatment  the  very  acute  inflammatory  symptoms 
begin  to  subside,  as  is  indicated  by  a  diminution  and  thin- 
ning of  the  urethral  discharge,  less  pain  on  urination,  and  a 
decrease  in  the  redness  and  swelling  of  the  meatus,  it  is  time 
to  begin  the  careful  and  judicious  use  of  bland  and  non- 
irritating  injections,  administered  by  the  patient  himself 
(hand  injections) ;  or  better  still,  warm  medicated  irrigations 
given  daily  or  every  other  day  by  the  physician.  In  all 
cases  when  a  hand  injection  is  ordered,  the  patient  should 
be  told  what  kind  of  a  syringe  to  purchase,  and  how  to 
use  it. 

A  good  urethral  syringe  is  made  of  smooth,  highly  polished 
hard  rubber  (Fig.  11),  or  rubber  and  glass,  with  a  bluntly 
conical  tip  (Fig.  12) ;  it  holds  from  two  to  four  drachms,  and 
the  plunger  should  work  smoothly  and  easily. 

These    syringes    are    sometimes    made    with    soft-rubber 


44     ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHEA 

tips,  but  they  possess  no  praetieal  adx  ;iiit;i<;'e  oNcr  the  :ill- 
liard-rubber  or  ghiss  ones,  and  cannot  be  kept  as  clean. 

A  ghiss  syringe  with   conical  tip  (Fig.  13)  is  much  less 
expensive  than  rubl)er,  and  at  the  same  time  quite  as  good, 

and  can  tlu'rcfore  be  used   in  hospital  and  disjx'nsary  work, 


Fic.  11. — Hard-ruhliiT  iiii'tliial  s.\iingc. 


Viu.  12. — Haiio\er  urethral  s>riu^c. 


Fig.  13. — Glass  urethral  syriiigo. 


Fig.  14. — Hard-rulihor  syringe  for  small  meatus. 


where  the  item  of  expense  is  an  important  one.    TJiis  syringe 
is  also  made  with  a  soft-rubber  conical  ti]).     For  patients 
with  a  very  small  meatus   a  hard-rubber  syringe  with  a 
small,  nipple-shaped  point,  may  be  ordered  (Fig.  14). 
Hand  injections  are  given  as  follows:  The  patient  urinates, 


TREATMENT  OF   TIIE   DECLININC  STAdE  lo 

wijx'S  the  iiK'Jitiis  with  a.  hit  of  g;iii/,c,  :iii(i  stjiiKniifi;  ii|)  uith 
the  penis  on  liic  stretch  niid  ;it,  right  iinfflcs  to  1iic  t)0(|y, 
gently  inserts  tJie  nozzle  of  the  eojnijietcly  filled  syringe  into 
the  meatus,  the  lips  of  wliicli  are  lightly  pressed  together 
from  side  to  side  against  the  syringe;  the  solution  is  then 
thrown  in  slowly  until  there  is  a  feeling  of  distention,  when 
it  may  be  allowed  to  escape,  or  if  not  too  uncomfortable, 
kept  in  for  a  minute  or  two.  While  the  fluid  is  being  in- 
jected the  patient  should  contract  the  compressor  urethrse 
muscle,  much  as  if  he  were  trying  to  hold  back  the  contents 
of  the  bladder,  in  order  to  prevent  the  passage  backward 
of  any  of  the  medication  into  the  posterior  urethra. 

Iland  injections  should  be  taken  two  or  three  times  daily, 
beginning  \\\t\\  a  warm  solution  of  sodium  chloride  (1  per 
cent.),  boric  acid  or  lead-water,  and  after  a  day  or  so,  with 
the  following  formulae  used  in  the  order  here  given: 


(1)  I^ — Zinc,  acetat.,  gr.  xij 

Liq.  plumb,  subacetat.,  3j 

Aq.  destillat.,  ad     gvj 

Or 

(2)  I^— Zinc,  sulphat., 

Plumb,  acetat.,  aa     gr.  vj-xij 

Aq.  destillat.,  ad     5vj 

Or 

(3)  I^ — Zinc,  sulphat., 

Aluminis,  aa     gr.  vj-xij 

Aq.  destillat.,  ad      gvj 


and,  later  (4),  potassium  permanganate  solution,  beginning 
w^th  1  to  8000  and  increasing  the  strength  gradually  up  to 
1  to  3000  or  even  1  to  2000. 

The  newer  silver  salts,  argyrol,  protargol.  albargin,  etc., 
have  been  highly  recommended  as  hand  injections,  but  have 


46     ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHEA 

not  i)rc)M'(l  as  effective,  in  tlie  author's  experience,  as  the 
formula?  given   above. 

If  the  hand  injection  causes  irritation,  as  it  sometimes 
does,  it  must  be  discontinued  for  a  time,  until  the  irritation 
has  abated,  and  then  resumed  cautiously,  using  a  weaker 


c 


Fig.  15. — Soft-rubber  catheters. 

solution  than  that  employed  when  the  signs  of  irritation 
developed. 

If,  however,  the  patient  can  come  to  the  surgeon  every 
day  during  the  subacute  stage,  great  benefit  will  l)e  derived 
from  the  use  of  warm  and  soothing  irrigations  tin-own  into 
the  bulb  of  the  urethra,  instead  of  the  hand  injections  above 
alluded  to. 


Fig.  16. — Bulbous  catheters. 

These  irrigations  are  gi\'en  daily,  or  every  other  day, 
and  if  properly  employed  will  materially  lessen  the  duration 
and  severity  of  the  attack.  The  patient,  having  urinated, 
stands  or  reclines,  and  the  operator  passes  a  small  soft- 
rubber  or  bulbous  silk  catheter,  properly  lubricated  (Figs.  15 


Tlil<:ATMI<:NT  OF   Till':   I>I<:CLININ(1  STAdh: 


47 


and  l(>),  into  the  l)iill),  aiid  injects  I'roni  fonr  to  (rif^ht  onnocs 
of  warm  medicated  fluid,  slowly  and  f^cntly,  l)y  means  of  a 
four-ounce  SN'rinf^e  and  coupler  (Fig.  2).  In  tliis  manner 
the  solution  waslies  out  and  medicates  the  entire  anterior 
urethra  and  escapes  at  the  meatus,  where  it  is  caught  in  a 
basin  (Fig.  17).  We  may  use  for  this  purpose  warm  solutions 
of  boric  acid  or  lead-water,  and  later,  weak  solutions  of 


Fig.  17. — Urethral  and  bladder  irrigation.      (.Original.; 


zinc  sulphate,  alum,  permanganate  of  potash,  and  finally 
nitrate  of  silver. 

In  the  decHning  stage  great  benefit  is  derived  from  the 
intelligent  use  of  the  antiblennorrhagics,  given  in  full  dose 
and  for  a  limited  period  only.  They  should  never  be  given 
during  the  acute  or  chronic  stage  of  the  disease.  Of  these 
the  pure  yellow  santal  oil  is  by  far  the  best:  it  is  put  up  in 
five-  and  ten-drop  capsules,  of  which  one  or  two  are  given 
an  hour  after  meals.  If  the  santal  oil  is  not  obtainable  or  is 
not  well  borne  by  the  stomach  we  may  substitute  capsules 


48     ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHEA 

of  copiiil);!,  or  a  (•oinl)iiiatioii  of  co]);!!!);!  ami  culx-hs,  wliicli 
sometimes  prove  of  value,  tlioiiuli  not  as  eflic-acioiis  as  tlie 
oil  of  saiidahvood. 

If,  as  is  sometimes  the  ease,  the  antihlciiiKurlia.uics  cause 
gastro-intestinal  disturbances,  cutaneous  rashes,  or  renal 
congestion  Avith  pain  and  uneasiness  in  the  lumbar  region, 
and  even  albumin  and  hyalin  casts  in  the  urine,  they  must 
be  discontinued  for  a  time,  and  when  resumed,  taken  in 
smaller  quantity. 

When  the  discharge  decreases  in  amount  and  becomes 
sticky  and  mucoid  in  character,  it  is  well  to  discontinue  the 
use  of  these  remedies,  as  they  are  apt,  if  continued  for  too 
long  a  period,  to  delay  the  cure  by  overstimulation  and 
irritation  of  the  urethral  mucous  membrane. 

If  the  foregoing  treatment  has  been  successful,  as  it 
usually  is  in  the  majority  of  cases,  the  patient  now  has  but 
a  trifling  urethral  discharge,  sometimes  only  seen  in  the 
morning,  with  flakes  and  shreds  and  j)erha})s  a  little  free 
pus  and  mucus  in  the  lu'ine. 

The  treatment  for  this  condition  is  so  similar  to  that  for 
chronic  gonorrhea  or  urethritis  that  the  reader  is  referred 
to  Chapter  VII,  w^here  all  the  details  will  be  found  fully 
described. 

TREATMENT  OF  ACUTE  POSTERIOR  GONORRHEA. 

As  soon  as  the  symptoms  of  acute  posterior  iiuohement 
develop  all  injections  and  other  instrumental  treatment  of 
the  urethra  must  be  suspended.  • 

The  i)atient  should  be  ke])t  very  quiet  and,  if  i)ossil)le, 
put  to  bed  for  a  few  days,  on  a  light,  nutritious  diet,  with 
the  testicles  properly  supi)orted.  Tlie  bowels  nnist  be  kept 
freely  open,  as  any  fecal  accumulation  in  the  rectum   is 


TREATMENT  OF   ACUTE   POSTEJUOU.   (lONOHKII EA       V.) 

liable  to  irritate;   tlic   infhiincd    <l(>('|)   iin'tlirii    ;iii(l    |>rostate 
ji^land. 

Antihlcnnorrhagics  are  stopj^ed,  iiiid  in  llicii-  ]>lae(;  one 
of  the  following  forniuhe  is  given: 

^ — Potass,  citrat.,  5J 

Tinct.  hyoscyam.,  5ij-iij 

Fid.  ext.  kav.  kav.,  5ss 

Aq.,  ad      gviij — M. 

Sig. — 5ss  in  water  one  hour  after  each  meal  and  once  during  the  night. 

I^ — Fid.  ext.  trit.  repens, 

Fid.  ext.  uvae  ursi,  aa.     giss 

Potass,  citrat.,  5ss 

Aq.,  ad      giv — M. 

Sig. — 3J~iJ  in  water  one  hour  after  each  meal  and  once  during  the  niglit. 

Still  water  may  be  taken  in  moderation.  Hot-water  bags 
over  the  bladder  and  on  the  perineum  give  relief,  as  do 
also  rectal  injections  of  hot  saline  solution  at  a  temperature 
of  115°  to  117°  F.;  or  the  hot  sitz  bath.  If  these  means 
do  not  control  the  frequency  in  urination,  pain,  and  tenesmus, 
we  may  be  obliged  to  resort  to  opium  suppositories  in  a 
guarded  manner,  using  just  enough  of  the  drug  to  keep  the 
patient  comfortable. 

If  retention  of  urine  occurs,  it  should  be  promptly  relieved 
by  catheterization  with  soft-rubber  or  silk  catheters,  as 
described  on  page  93. 

When  the  frequency  in  urination,  vesical  tenesmus,  and 
other  acute  inflammatory  symptoms  begin  to  subside,  we 
may  then  carefully  resume  local  urethral  treatment,  and 
allow  the  patient  to  be  up  and  about. 

There  are  some  cases,  how^ever,  which  in  spite  of  the 

above  treatment  show  no  improvement,  as  to  their  acute 

symptoms   continue   unabated   for   days   and   even   weeks. 

In    this    class   of    cases    great   benefit   will    sometimes    be 

4 


50      ACUTE  AXTERIOh'  AXD  I'OSTEIUOR  GONORRHEA 

derived  from  the  judicious  use  of  small  irrigations  of  warm 
boric  acid  or  salt  solution  thrown  into  the  deep  urethra 
and  bladder  by  means  of  a  soft  catheter  and  four-ounce 
syringe. 

It  is  always  ad\isable  in  acute  posterior  gonorrhea,  but 
especially  in  the  severe  cases,  to  make  occasional  rectal 
examinations  of  the  prostate,  seminal  vesicles  and  bladder 
base,  as  by  this  exploration  we  learn  their  true  condition, 
and  are  i)repared  to  treat  efficiently  and  i)ronii)tl>'  any  \ms- 
formation  that  mav  occur  in  or  about  these  structures. 


CHAPTKR   IV. 

COMPLICATIONS  OF  ACUTE  AXTEIUOK  (;().\()li- 
RIIEA  AND  THEIR  TREATMENT. 

BALANITIS. 

Balanitis  is  an  acute  or  chronic  inflammatory  process, 
attacking  the  mucous  membrane  of  the  glans  penis,  and 
if  accompanied  by  inflammation  of  the  mucous  membrane 
lining  the  prepuce,  is  called  balanoposthitis. 

It  is  caused  by  inicleanliness  or  by  allowing  smegma  or 
gonorrheal  pus  to  collect  beneath  the  foreskin,  where  it 
sets  up  more  or  less  inflammation.  The  condition  usually 
occurs  in  persons  with  a  long,  tight  prepuce,  a  condition 
which  prevents  retraction  and  proper  cleansing  of  the  parts. 

The  mucous  membrane  becomes  red,  thickened,  and 
covered  with  a  thin,  purulent,  and  very  offensive  secretion; 
this  is  followed  by  swelling  of  the  glans  penis,  which  may  be 
covered  with  irregular  patches  of  excoriation;  these,  if 
untreated,  may  go  on  to  superficial  ulceration. 

Treatment. — The  parts  must  be  kept  absolutely  clean  by 
washing  in  hot  water,  or  hot  bichloride  solution  (1  to  5000), 
and  separated  by  means  of  absorbent  gauze  wet  in  a  weak 
solution  of  sulphate  of  zinc,  lead-water,  or  boric  acid.  (See 
Figs.  6,  7,  8,  and  9 — slit  gauze  dressing.) 

When  the  acute  process  has  subsided  the  preputial  cavity 
may  then  be  treated  by  careful  cleansing  and  drying,  and 
the  application,  night  and  morning,  of  a  dusting  powder 
composed  of  equal  parts  of  aristol  and  powdered  boric  acid. 


52    .    COMPLICATIONS  OF  ANTERIOR  GONORRHEA 

If  the  i)r(.'i)uct'  cannot  be  retracted,  the  subpreputial  space 
may  be  washed  out  with  any  of  the  above  solutions,  or  plain 
hot  water,  these  being  injected  with  an  ordinary  hand 
syringe  or  irrigator.  If  there  is  considerable  swelling  of 
the  prepuce  and  glans  penis,  the  patient  must  be  kept  on 
his  back,  with  the  penis  enveloped  in  gauze,  wet  in  cold 
lead-water,  bichloride  solution  (l  to  5UU0),  or  aluminum 
acetate  solution.  When,  as  a  result  of  the  above  treatment, 
the  parts  have  returned  to  a  normal  condition,  circumcision 
should  be  strongly  advised. 

PHIMOSIS. 

Phimosis  is  that  deformity  of  the  prepuce  which  renders 
its  retraction  behind  the  glans  penis  impossible  (Fig.  18). 

The  condition  may  be  congenital  or  acquired;  the  latter 
results  from  a  balanitis  or  balanoposthitis,  M'hich  by  its 
irritation  causes  edema,  redness,  and  swelling  of  the  j)repuce, 
this  swelling  becoming  so  great  as  to  cause  narrowing  of  the 
])reputial  orifice. 

The  patient  should  be  kept  very  quiet,  in  bed  if  possible, 
and  the  cavity  of  the  prepuce  thoroughly  irrigated  several 
times  daily  with  hot  bichloride  solution,  1  to  5000.  It  is 
well  to  keep  the  penis  enveloped  in  absorbent  gauze,  which 
is  constantly  wet  with  cold  lead-water,  mild  bichloride 
solution,  boric  acid,  or  aluminum  acetate. 

Congenital  phimosis  is  frequently  complicated  by  bands 
or  adhesions  running  between  the  glans  and  the  inner 
surface  of  the  prepuce,  and  may  or  may  not  give  rise  to  mild 
or  \ery  severe  attacks  of  balanoposthitis,  with  painful  and 
annoying  manifestations.  (For  the  further  discussion  and 
treatment  of  this  condition  see  Chapter  XVIII.) 


/'AUAI'If/MOS/S 


53 


III  acqiiii-cd  pliiinosis,  Jil'ter  tin;  acute  coiKlititdi  Im-^ 
snl)si(]o(l,  circiiincisioii  should  he  strongly  iulviscd  us  the 
only  guarantee  against  ;i  ])ossil)le  return  oF  the  aft'cetion. 
(See  Chapter  XVI II.) 


Fig.   is. — Phimosis.     (Author's  case.) 


PARAPHIMOSIS. 

Paraphimosis  is  that  condition  in  which  the  prepuce  has 
been  retracted  or  has  slipped  behind  the  corona  glandis, 
and  cannot  be  readily  brought  forward  (Fig.  19).  The 
small  preputial  orifice,  which  is  now  pushed  back  behind 
the  corona,   forms  a   band   of  constriction  on  the  dorsal 


54       COMPLICATIONS  OF  ANTERIOR  GONORRHEA 

siirfacr  of  the  poiiis,  wliicli,  prcxcutinti;  I't'tuni  circuliition, 
causes  more  or  less  deformity  of  the  orjiaii  from  edema. 
This  strangulation  of  tlie  penis  may  develop  rai)idly  or 
gradually,  and  when  well  established,  causes  great  dis- 
comfort, and  if  neglected,  may  even  go  on  to  nlccratiou  and 
gangrene  of  the  prepuce  and  glans  ])enis. 


Fig.  19. — Paraphimosis.     (Author's  case.) 


Treatment. — The  first  requirement  in  the  treatment  of 
this  condition  is  immediate  reduction  of  the  deformity. 
This  can  often  be  accomplished  in  the  following  manner: 

The  organ  is  thoroughly  washed  and  dried,  then  with 
the  two  thumbs  pressing  on  the  end  of  the  gland,  and  the 
index  and  ring  fingers  l)ehind  the  constriction  and  corona 
(Fig.  20),  the  blood  is  entirely  massaged  out  of  the  glans, 
which,  being  thus  reduced  in  size  and  softened,  is  pushed 
back  through  the  constricting  ring  and  the  prepuce  drawn 
forward. 


PARA  I'll  fM()>S/S  f)') 

Should  tJiis  procedure  liiil,  owiiii;'  to  the  1  i;;ht  iiess  of  the 
coiistrietioii,  ii  siiiiill,  loii^it iidiiiiil  incision  must  he  ninde 
coniplctcly  throu^'Ji  tJic  constrictinj;  hiind,  on  tlic  dorsal 
surrace,  after  whicJi  tlic  <^laiis  can  Ix;  reachls-  reduced  and 
the  i)rei)iice  IjrongJit  forward,  the  Htth-  woinid  heiiif^  dresserl 
witli  sterile  g'auze,  and  the  prc])ntial  ca\ity  ke])t  clean. 


Fig.  20. — Reduction  of  paraphimosis. 


As  both  these  procedures  are  Hable  to  be  more  or  less 
painful,  it  may  be  necessary  in  some  cases  to  give  the  patient 
a  general  anesthetic;  a  few  ^yhiffs  of  gas  answering  the 
purpose.  Usually,  however,  a  local  anesthetic,  such  as  1 
per  cent,  cocain  or  novocain,  will  be  all  that  is  necessary. 
In  some  cases  freezing  of  the  parts  with  the  ethyl  chloride 
spray  will  answer  the  purpose  perfectly. 


50       COMPLICATIONS  OF  ANTERIOR  GONORRHEA 

PERIURETHRAL  ABSCESS. 

Periurethral  abscess  occurs  on  tlie  luuler  surface  of  tlie 
penis,  anywliere  between  tlie  frenum  and  the  penoscrotal 
junction,  the  region  of  the  freninii  being  the  fa\'orite  location. 
The  abscess  may  be  either  uni-  or  bilateral,  the  latter  l)eing 
especially  frequent  near  the  frenum  (Fig.  21). 


Fig.  21. — Pciiiucthral  abscess.      (Author's  case.) 

This  condition  occurs  as  a  conii)licati()n  of  both  acute  and 
chronic  gonorrhea,  and  is  the  result  of  infection  of  a  peri- 
urethral follicle,  which,  as  a  rule,  goes  on  ra])idl>'  to  abscess 
formation. 

It  appears  at  first  as  a  small,  hard  mass,  but  when  fully 
developed  it  Jias  all  tlie  characteristics  of  an  ordinary  acute 
abscess.  If  very  large,  it  may  impinge  on  the  caliber  of  the 
urethra  anfl  cause  more  or  less  obstruction  to  urination. 


FOfjjcr/fjTis  57 

Treatment.  I'iiiiciils  siin'('riii<;-  IVoiii  lliis  rdiidii  ion  -lioiiM 
l)C  kept  very  quiet  oi-  |)nt  to  hcd,  uml  ;ill  injections  and 
instrumental  treatment  of  tJie  uretJira  st(>j>j)ed  for  a  time. 
The  inflamed  parts  should  be  kept  at  rest  and  covered  with 
cold  lead-water,  alum  acetate  solution,  or  jtidiloiidc  of 
mercury  solution,  1  to  r)()()().  In  some  cases  tJiis  may  lead 
to  a  disappearance  of  the  swelling!;,  l)ut  recurrence  is  the 
rule  rather  than  the  exce])tion,  esj)ccially  with  ii  frcsli  in- 
fection or  an  exacerbation  of  the  urethritis. 

If  suppuration  occurs,  the  abscess  should  be  laid  freely 
open,  swabbed  out  with  pure  phenol  or  tincture  of  iodin 
and  packed  with  sterile  gauze. 

It  is  important  to  remember  that  these  abscesses  should 
not  be  opened  until  suppuration  is  well  advanced,  as  by 
that  time  the  urethral  orifice  of  the  follicle  is  closed  by  a 
plug  of  inflammatory  material,  which  prevents  the  urine 
from  leaking  into  the  abscess  cavity,  and  causing  a  urinary 
fistula,  which  is  very  difficult  to  cure  in  this  region. 

FOLLICULITIS. 

Folliculitis  may  occur  at  any  time  during  the  course  of  a 
urethral  gonorrhea,  and  is  due  to  infection  of  one  or  more 
of  the  little  follicles  which  are  situated  between  the  layers 
of  the  prepuce  (Fig.  22),  either  on  its  sides  or  dorsum, 
opening  on  its  free  border  or  on  its  mucous  surface,  or  of 
those  on  the  under  surface  and  near  the  median  line  of  the 
penis,  even  as  far  back  as  the  scrotum. 

In  the  acute  stage  the  tissues  about  these  follicles  are 
acutely  inflamed  and  frequently  a  small  drop  of  pus  exudes 
or  can  be  pressed  from  the  tiny  orifice  of  the  abscess  ca^-ity. 
If  neglected,  the  infection  passes  into  the  subacute  and  then 


58        COMPLICATJOXS  OF  ANTERIOR  GOXORRIIEA 

iutt)  the  cliniiiit-  stagt',  and  if  unrccouiiiziMl  or  uiitrcati'd,  is 
very  liable  to  lead  to  the  infeetioii  of  women  and  to  eaiise 
auto-infeetioii  of  the  bearer. 

Treatment. — The  parts  should  l)e  cleansed  in  the  usual 
manner,  and  affected  follicles  resected  under  local  anesthesia, 
and  a  light  dressing  a]i]ili(>d. 


Fig.  22. — Preputial  loUiculiti.s.      (Author's  case.) 


Paraurethral  FoUiculitis. — 1  )uring  the  course  of  a  urethral 
gonorrhea  the  follicle  in  either  one  or  both  lips  of  the  meatus 
may  become  infected  from  the  urethral  discharge,  thus 
giving  rise  to  a  small  abscess,  from  the  minute  orifice  of 
which  a  little  drop  of  pus  escapes  or  can  be  pressed.  In 
some  cases  the  follicle  forms  a  sinus,  opening  on  the  mucous 
membrane  of  the  fossa  navicularis,  thus  constituting  a  true 
urinary  fistula.     This  form  of  folliculitis,  if  uncured,  may 


COWVKIIITIH  59 

ciuisc  the  iiircclioii  of  vvomcii  uiid  Miito-iiifcct ion  ol'  llic  in- 
dividual hiinscir.  In  many  cases  ol'  jx'riiirctliral  al)Sf»'ss, 
and  of  paraurctliral  folliculitis  which  \vc  have  exairiiiied, 
gonococci  have  been  demonstrated,  holh  })y  niicroscoi>i(; 
examination  and  culture  experiments,  in  the  abscess  and 
urethral  pus. 

Treatment. — The  little  abscess  must  be  laid  freely  open, 
curetted,  and  the  raw  surface  touched  with  ])urc  phenol, 
ji;reat  care  being  taken  to  avoid  cauterization  of  the  ad- 
joining mucous  membrane. 


COWPERITIS. 

Cowper's  glands,  like  the  urethral  follicles,  may  be  the  seat 
of  abscess  formation,  the  urethral  infection  traveling  down 
their  ducts,  which  open  on  the  floor  of  the  bulb,  the  glands 
themselves  being  situated  between  the  anterior  and  posterior 
layers  of  the  triangular  ligament  in  the  substance  of  the 
compressor  urethrse  muscle.  As  a  rule,  but  one  gland  is 
affected  at  a  time.  At  first  the  abscess  is  situated  in  the 
perineum  on  either  side  of  the  median  line,  but  if  large  it 
may  break  through  the  anterior  or  posterior  layer  of  the 
triangular  ligament  and  burrow  forward  or  backward  a 
long  distance  along  the  urethra,  and  by  pressure  on  the  canal, 
interfere  markedly  with  urination,  or  even  cause  complete 
retention  (Fig.  23).  We  have  recently  seen  a  case  in  which 
the  abscess  not  having  been  incised,  a  cyst  had  formed 
which  resulted  in  chronic  and  complete  retention  lasting 
nearly  two  years,  necessitating  catheterization  four  times  a 
day  during  that  entire  period.  Excision  of  the  cyst  afforded 
complete  relief. 


60        COMPLICATIONS  OF  ANTERIOR  GONORRHEA 

Treatment. — WIrmicmt  ;i  cowptTitis  develops  tlio  patient 
must  1)0  kept  in  bed,  and  all  urethral  instrunu'iitation 
stopped.  If  fluctuation  cannot  ho  dotoctod,  cold  load-wator, 
aluminum  acetate,  or  bichloride  of  nurcury  solution,  applied 
locally,  may  cause  resohition  in  some  cases;  if,  on  tiio  other 
hand,  fluctuation  can  he  j)hiinl>  felt,  the  ])ns  must  ho  im- 
modiatolv  evacuated. 


Fig.  2.3. — Suppurative"  fowporitis,  left  .side.      (Author's  cawc.) 


The  patient,  having  been  anesthetized,  is  properly  pre- 
pared for  operation  and  placed  in  the  lithotomy  position. 
A  full-sized  sound  is  then  passed  to  the  deep  urethra,  and 
held  there  directly  in  the  median  line  by  an  assistant,  thus 
rendering  the  urethra  prominent  and  preventing  it  from 
being  cut  or  injured  during  the  operation,  as  in  many  of  those 


ADENITIS  61 

cases,  after  evaciuition  of  the  abscess,  the  hull)  of  the  nretliru 
can  he  (hstiiictly  seen  haiif^iiig  in  the  wound,  and  is  tlius 
rendered  liable  to  injury  if  not  made  prominent  by  a  sound. 
The  abscess  is  then  freely  incised;  if  burrowing  has  occurred 
in  any  direction,  it  must  be  followed  up  by  free  incisions 
which  thoroughly  efface  all  blind  pockets  or  cul-de-sacs. 
The  nbscess  cavity  is  then  irrigated  with  bicliloridc;  of 
mercury  solution,  packed  lightly  with  sterile  gauze  fto 
prevent  pressure  on  the  urethra,  with  consequent  retention 
of  urine),  and  covered  with  a  large  dressing,  held  in  place 
by  a  T-bandage  or  double  spica. 

LYMPHANGITIS. 

Inflammation  of  the  lymphatic  vessels  of  the  penis  may 
occur  during  the  acute  stage  of  gonorrhea  or  urethritis. 
The  vessels  can  be  felt  as  hard  and  painful  cords  running 
along  the  dorsum  of  the  organ  up  into  the  groins,  where 
they  empty  into  the  inguinal  glands.  The  penis  becomes 
edematous  and  enlarged,  and  the  course  of  the  lymphatics 
is  marked  by  red  lines  beneath  the  skin.  Suppuration 
rarely,  if  ever,  occurs. 

Treatment. — The  patient  should  be  kept  in  bed  and  the 
penis  enveloped  in  gauze  kept  w^et  with  cold  lead-water, 
aluminum  acetate,  or  bichloride  of  mercury  solution.  All 
intra-urethral  treatment  should,  of  course,  be  suspended  for 
a  time. 

ADENITIS. 

The  inguinal  glands  frequently  become  enlarged  and 
tender  during  an  acute  gonorrhea,  but,  fortunately,  they 
very  rarely  suppurate. 


62        COMPLICATIONS  OF  ANTERIOR  GONORRHEA 

Treatment. — Patients  in  whom  this  compHcation  occurs 
should  be  kept  as  quiet  as  possible,  or  put  to  bed,  and  a 
cold  wet  dressing  of  aluminum  acetate  or  bichloride  of 
mercury  solution  (1  to  500)  is  applied,  over  which  is  placed 
an  ice-cap. 

If  in  spite  of  the  above  treatment  suppuration  occurs, 
the  pus  must  be  immediately  evacuated  by  free  incision 
or  by  puncture  followed  by  irrigation  and  injection  of  the 
abscess  cavity  with  iodoform  ointment.  (For  the  details 
of  these  measures  see  page  217.) 


CHAPTER  V. 

COMPLICATIONS  OF  ACUTE  POSTERIOR  (iOXOP.- 
RHEA  AND  THEIR  TREATMENT. 

PROSTATITIS,  ACUTE  AND  CHRONIC. 

Acute  prostatitis  is  a  very  common  complication  of  acute 
posterior  gonorrhea. 

The  inflammation  in  the  posterior  urethra  spreads  along 
the  prostatic  ducts  and  the  gland  becomes  hyperemic  and 
swollen.  This  gives  rise  to  a  sense  of  fulness  in  the  perineum 
and  rectum,  accompanied  by  vesical  and  rectal  tenesmus, 
with  more  or  less  pain  in  the  prostate  as  the  fecal  masses 
press  upon  it  as  they  pass  through  the  rectum. 

In  some  cases  there  is  great  difficulty  in  urination,  which 
may  go  on  to  complete  retention.  Frequently  there  are 
painful  nocturnal  pollutions,  which  are  sometimes  bloody. 
Rectal  examination  shows  the  gland  to  be  enlarged,  hot,  and 
painful;  firm  and  tense  in  some  cases,  but  soft  and  boggy 
in  others.  The  slightest  pressure  by  the  examining  finger 
is  exceedingly  painful  and  causes  an  exudation  of  purulent 
prostatic  fluid  from  the  meatus. 

As  a  general  rule,  the  congestion  subsides  as  the  urethritis 
improves,  but  there  are  some  cases  in  which  the  inflammation 
goes  on  to  abscess  formation.  This  complication,  when  it 
does  occur,  is  a  very  grave  and  sometimes  even  fatal  one, 
unless  promptly  and  radically  treated. 


6-i       COMPLICATIONS  OF  POSTERIOR  GONORRHEA 

There  may  he  one  large  abscess,  situated  in  either  hiteral 
lobe,  or  the  posterior  median  })ortion;  or  se^•eral  smaller 
ones  scattered  irregularly  thrc)Ughout  the  gland  substance. 

Unless  recognized  and  evacuated,  the  abscess  may  rupture 
either  into  the  bladder,  urethra,  rectum,  peritoneal  cavity, 
or  perineum;  rupture  into  the  urethra  being  the  most  fre- 
quent. Suppuration  is  ushered  in  by  an  agonizing  and 
constant  throbbing  pain  in  the  j^rostate,  sweating  rigors, 
rise  of  temperature,  and  frecjuent  and  painful  djibbling  of 
the  urine,  which  may  even  go  on  to  complete  retention, 
caused  by  occlusion  of  the  prostatic  urethra  and  by  com- 
pressor spasm. 

Rectal  examination  shows  the  prostate  to  be  enlarged, 
hot,  exquisitely  painful,  and  throbl)ing.  Fluctuation  is 
readily  detected  if  the  abscess  points  toward  the  rectum, 
but  with  more  difficulty  if  in  other  directions.  In  some 
cases  the  gland  is  so  swollen  and  tender  that  only  the  finger- 
tip can  be  introduced  into  the  rectum. 

If  the  abscess  ruptures  into  the  urethra,  as  it  frequently 
does,  either  spontaneously  or  as  the  result  of  catheterization 
for  retention,  the  patient  experiences  a  sudden  sensation 
as  if  something  had  "broken  or  given  way  at  the  neck  of 
the  bladder,"  and  immediately  passes  more  or  less  blood- 
stained and  usually  foul-smelling  pus  and  urine  by  the 
urethra,  following  which  (rupture  of  the  abscess)  there  is  a 
sudden  cessation  of  all  the  above  painful  and  distressing 
symptoms,  with  a  corres])()n(ling  droj)  in  the  temperature. 

Treatment. — Patients  suffering  from  acute  prostatitis  should 
be  put  to  l)ed  immediately.  All  antiblenorrhagics,  injec- 
tions and  instrumental  treatment  must  be  stopped  and 
the  urine  rendered  bland  by  copious  draughts  of  water 
and  the  use  of  one  of  the  following  formulie: 


puos'i'A'rri'js,  A('uti<:  and  ciiromc  ('..') 

I^ — Potass,  citrat.,  5J 

Tr.  hyosi^yami,  Sij-i'j 

Fid.  cxt.  kiiv.  k;i\-.,  5.ss 

Aq.,  !ui      ,',  viij — M. 

Sig. — 5ss  ill  water  oik;  hour  .■iflcr  inr.ils  iinil  diiriii;.'  I  he  lu'Kht. 

I^ — Potass,  citrat.,  J,] 

Tr.  hyoscyami,  .oij-iij 

Inf.  buchu.,  ad      ^viij — .VI. 

Sig. — 5ss  in  water  one  hour  after  meals  and  ;i(  ruKht. 

The  bowels  should  be  iiioxcd  freely  every  clay,  usiiij^ 
vegetable  catliartics  for  the  purpose.  The  use  of  sahnes 
is  inadvisable,  owing  to  their  magnesium  sulphate  content, 
which  renders  the  urine  irritating.  Hot-water  bags  over  the 
bladder  and  perineum  are  often  useful,  ^>ry  valuable  also 
are  hot  rectal  irrigations  of  normal  salt  solution  given  daily 
or  twice  a  day  by  means  of  the  author's  soft-rubber  tubes 
(Fig.  24)  in  the  following  maiuier: 

The  patient  lies  down  on  his  side  with  the  buttocks  near 
the  edge  of  the  bed  or  table.  A  five-quart  douche  bag  filled 
with  saline  solution,  at  a  temperature  of  115°  to  117°  F., 
is  so  suspended  that  its  lower  end  is  about  a  foot  above  the 
patient's  hips.  The  author's  double  tube,  thoroughly  lubri- 
cated with  vaselin,  is  now  inserted  very  gently  for  a  distance 
of  about  three  inches,  so  that  the  eye  of  the  inflow  tube 
rests  against  the  gland.  The  fluid  in  the  bag  is  now  allowed 
to  flow  slowly  into  the  rectum  through  the  inflow  tube, 
and  out  again  through  the  outflow  tube,  the  posterior 
aspect  of  the  prostate  being  thus  continually  bathed  with 
the  hot  saline  solution.  Each  treatment  should  last  from 
twenty  to  thirty  minutes.  By  the  use  of  a  bath  thermometer 
in  the  douche  bag  and  the  addition  of  more  hot  saline,  from 
time  to  time,  the  irrigating  fluid  can  be  kept  constantly 
at  proper  temperature. 

These  irrigations  may  sometimes  result  in  the  develop- 
5 


()()       COMI'LICATJOXS  OF   POSTPJRWR   dOXOh'UH KA 

meiit  of  hemorrhoids,  hut  we  have  found  that  the  Hberal 
use  of  carbolized  vasehn  as  a  hihricaut  for  the  tubes  prevents 
this  ct)nipHcation  in  the  vast  majority  of  eases.  Sliouhl 
hemorrhoids  develop  the  irri<;ations  are  stopped  for  a  few 
days,  and  the  patient  told  to  use  suppositories  of  tannic 
acid. 


INFLOWO ~=^ 


OUTFLOW 
Fig.  24. — Author's  doublc-currcut,  soft-rubber  rectal  irrigating  tubes. 

After  each  of  these  treatments  the  patient  should  be 
directed  to  rest  for  a  short  time,  if  possible.  In  addition 
to  the  above  measures  the  use  of  the  hot  sitz  bath  taken 
at  bedtime  will  often  prove  very  beneficial  in  lessening 
pelvic  congestion.     Very  rarely   suppositories   of  morphin 


PROSTATJTfS,   ACUTK  AND  C II  HON  J  C  07 

or  opium,  \\i(li  l>cllii(loiiiiii,  iiiiiy  liiixc  to  l)c  gi\'cii  to  control 
the  pain  and  tenesmus. 

Should  retention  occur,  the  urine  must  })e  drawn  with  a 
soft-rubber  or  woven-silk  cutlu^ter,  and  a  little  warm  boric 
acid  solution  injected  into  the  bladder  and  allowed  to  remain. 
It  is  also  good  practice  to  gently  irrigate  the;  urethra  with 
the  same  solution  as  the  catheter  is  slowly  and  carefully 
withdrawn.  Catheterization  failing,  we  are  then  obliged 
to  resort  to  suprapubic  aspiration  of  the  })ladder.  (See 
page  180.) 

Regular,  systematic  examination  of  the  prostate,  per 
rectum,  will  keep  us  informed  as  to  the  condition  of  the 
gland  and  the  possibility  of  abscess  formation. 

Should  abscess  of  the  prostate  develop,  immediate  opera- 
tive treatment  is  imperative. 

The  pus  may  be  evacuated  by  either  of  the  following 
methods : 

First  Method. — ^The  perineum  having  been  prepared  and 
draped  as  usual,  the  patient,  under  general  anesthesia,  is 
placed  in  the  lithotomy  position  and  a  grooved  staff  is 
passed  to  the  bladder  and  held  there  exactly  in  the  median 
line  by  an  assistant,  who  at  the  same  time  retracts  the 
scrotum,  thus  exposing  the  operative  field  and  rendering 
the  urethra  prominent,  which  prevents  its  injury  during 
the  operation.  Great  care  must  also  be  taken  not  to  wound 
the  rectum,  which  accident  can  be  prevented  by  thorough 
retraction  of  the  wound.  A  longitudinal  incision  is  then 
made  in  the  median  raphe  of  the  perineum,  extending  to 
within  half  an  inch  of  the  anus  and  carried  far  enough  for- 
ward to  give  a  good,  free  wound,  at  the  bottom  of  which 
the  prostate  is  found.  The  abscess  is  then  freely  incised, 
irrigated  with  hot  saline  solution,  and  packed  with  moist 


68       COMPLICATIONS  OF  POSTERIOR  GONORRHEA 

sterile  gauze.  An  onliimry  ,i;;iir/('  drossing  is  applied  and 
held  in  place  by   a  T-hanilage. 

Second  Method. — In  some  eases  the  abscess  is  foinid  to 
be  difficult  of  access  by  this  method.  Under  such  circum- 
stances the  urethra  .should  be  opened  near  the  apex  of  the 
prostate,  using  the  staff  as  a  guide,  as  in  the  operation  of 
external  urethrotomy  (described  on  i)age  Ki.')).  The  fore- 
finger is  then  introduced  into  the  canal  and  i)ushed  back 
into  the  bladder,  dilating  the  pro.static  urethra  and  splitting 
the  lateral  lobes  of  the  prostate,  thus  opening  up  any  abscess 
cavities  in  the  gland.  All  partitions  between  separate 
cavities  should  be  thoroughly  broken  down  to  insure  free 
drainage.  A  large  perineal  tuloe  is  then  passed  tlirough  the 
perineal  wound  into  the  ])ladder,  and  secured  in  place  by 
a  heavy  silk  suture;  the  wound  is  lightly  packed  with 
gauze  and  a  dressing  a])plied  as  above. 

Chronic  Prostatitis. — Chronic  prostatitis,  as  a  result  of 
acute  or  chronic  jxjsterior  gonorrhea,  or  urethritis,  is  of 
very  frequent  occurrence,  and  is  often  the  cause  of  chronic 
urethral  discharges.  It  must  be  remembered  that  chronic 
prostatitis  may  also  be  the  result  of  posterior  urethritis, 
caused  by  excessive  masturbation  in  young  boys,  and  by 
sexual  excesses  and  abnormalities  in  men  of  riper  years; 
also,  by  long-continued  and  ungratified  sexual  desire.  A 
chronically  congested  condition  of  the  prostate  is  frequently 
observed  following  some  of  the  so-called  al)()rti\e  methods 
of  treating  acute  gonorrhea,  especially  the  Janet  method; 
and  the  forcible  injection  of  solutions  into  the  deep  urethra 
and  bladder  by  means  of  a  large  hand  syringe. 

Excessive  motor-cycling  and  horseback  riding,  and 
especially  the  all  too  prevalent  "withdrawal"  during 
intercourse,   to  prevent   concei)tion,   are  also,   very   i)otent 


PROSTATITIS,   AdUTK   AND  ClIltONIC  iV.) 

cuiiscs  of  clii'oiiic  posterior  iirclliriil  coii^csl  ion  iiiid  pros- 
tatitis. 

Symptoms.  The  symptoms  of  (;liroi)i(;  i)rostatitis  arc 
very  marked  in  some  cases  and  j)ra.(;ti('ally  absent  in  others. 
There  may  l)e  some  frequency  in  urination,  increased  l)\' 
sexual  and  alcohoHc  indulgences;  nocturnal  pollutions  and 
premature  and  even  painful  ejaculation  may  be  present, 
the  ejaculate  being  blood-stained  in  some  instances.  Some 
subjects  lose  their  sexual  desire,  or  may  even' become  totally 
impotent.  The  urine  may  be  clear  or  more  or  less  cloudy, 
as  a  result  of  the  posterior  urethritis,  which  is  almost  always 
present  in  these  cases,  and  which  gives  rise  to  a  varying 
amount  of  urethral  discharge. 

In  advanced  cases  there  may  be  an  oozing  of  prostatic 
fluid  from  the  meatus  after  urination  and  defecation,  es- 
pecially when  the  bowels  are  constipated;  this  greatly 
alarms  nervous  and  excitable  individuals,  as  they  think 
they  are  losing  their  seminal  fluid. 

Some  subjects  complain  of  a  sensation  of  fulness  and 
distress  in  the  rectum  and  perineum,  which  is  greatly  in- 
creased by  defecation  and  coitus,  also  by  long  walks,  over- 
exercise,  motoring,  bic,ycle  and  horseback  riding,  and  by 
standing  a  long  time.  Catching  cold  aggravates  any  or 
all  of  the  above  symptoms. 

Diagnosis. — The  diagnosis  of  chronic  prostatitis  can  only 
be  arrived  at  by  making  a  careful  rectal  examination,  when 
the  gland  will  be  felt  (Fig.  25),  either  enlarged,  tender, 
and  boggy,  or  very  tense  and  firm.  Digital  pressure  on 
the  gland  will  usually  cause  an  oozing  from  the  meatus  of 
prostatic  fluid,  which  should  always  be  collected  and  ex- 
amined microscopically.  As  a  general  rule,  the  enlargement 
is  most  marked  on  the  left  side. 


70       COMPLICATIONS  OF  POSTERIOR  GONORRHEA 

Treatment. — If  tlio  ^^\ii\u\  is  soft  aiul  l)<).i;gy,  it  slionld  he* 
massaycd  about  every  five  or  seven  days;  hut  if  firm  and 
tense,  very  little  if  any  henefit  will,  as  a  rule,  be  derived  from 
this  treatment,  imless  the  massage  is  preceded  for  a  week 

or  ten  da\s  b\-  daiK'  rectal  irrigations  of  hot  saline  solution. 


Hla.Ulor. 


AmpuUated  ond 
of  vastlcfercns. 


Sominiil  vesicle. 


Prostatu   gland. 


Fu:.  25. — Photograph  of  bluddcr  baae.     (College  of  Phj-dicians  and 
Surgeons.) 


which  soften   the  gland   and   ])erinit   the  expression   of   its 
contents.     ^Massage  is  always  contra-indicated  when  there 
is  a   well-marked   ])yuria,   owing  to  the  danger  of   setting 
up  an  epididymitis. 
The  chronic  urethrocystitis,  which  is  found  in  conjunction 


El'JDIDYMITIS   AND    l<:i'l  1)1  l)Y MO  OUC II ITl S         71 

with  this  ty|)(;  of  |)r()stiititis,  should  be  hiiiHllcd  in  ihc  iii;iii- 
iier  dcscrilx'd  in  the  chuptcr  devoted  to  it.  fS('e  ('hjiptcr  \'l  Ij 
Tlie  i)atieiit's  general  condition  should  he  looked  into 
and  improved  hy  general  hygienic;  measures  and  tonics. 
Other  local  treatment  of  the  prostate,  besides  massage  and 
hot  irrigations,  consists  in  the  use  of  one  of  the  following 
rectal  snppositories,  used  once  or  twice  daily: 

I^ — Ung.  hydrarg.  (50  por  cent.),  gr.  xx 

Antipyrin,  gr.  v 

Ichthyoli,  gr.  v-x 

The  following  formula  will  also  be  found  of  value  in  some 
cases  of  clironic  prostatitis: 

IJ — Ext.  bcUadon.,  gr.  \ 

CoUargol,  gr.  iij 

Anesthesin,  ■  gr.  x 

01.  theobrom.,  q.  s, 

M. — Ft.  suppos.  No.  1. 

Sig. — Use  one  suppository  at  bedtime. 

Considerable  benefit  may  also  be  derived  from  the  use 
of  the  Oudin  high-frequency  spark  applied  to  the  prostate 
by  means  of  a  rectal  electrode  (Fig.  26),  every  week  or 
ten  da  vs. 


137 


Fig.  26. — Glass  rectal  electrode. 

EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS. 

Epidid^^mitis  is  one  of  the  most  frequent  complications 
of  acute  posterior  gonorrhea,  and  consists  of  an  acute  in- 
flammation of  the  epididymis,  which,  if  it  extends  to  the 
testicle,  is  called  epididjuio-orchitis. 


72     ,  COMPLICATJOXS  OF  POSTERIOR  GONORRHEA 

111  severe  cases  the  \"as  det'ereiis  is  also  iiixoKcd  in  the 
iiiHaiiiiiiatory  jjroeess  (aeiite  t'unieuHtis),  and  the  cavity 
of  the  tunica  va<>;inaHs  may  be  more  or  less  distended  with 
serum.  This  condition  is  spoken  of  as  acute  hydrocele, 
and  may  cither  disappear  spontaneously  or  remain  as  a 
chronic  ])r()cess. 

Epididymitis  or  epididymo-orchitis  may  appear  during 
any  stajje  of  a  gonorrhea,  either  spontaneously  or  as  the 
result  of  trauma,  such  as  ^■iolent  physical  exertion,  unskilful 
instrumentation,  etc. 

It  is  the  result  of  an  extension  of  the  inflammatory  process 
from  the  floor  of  the  posterior  urethra  into  the  ejaculatory 
duct,  and  thence  to  the  epididymis  and  testicle.  It  is  uni- 
lateral in  the  majority  of  cases,  although  l)oth  glands  may 
be  attacked  at  the  same  time,  or  successively. 

Symptoms. — The  symptoms  of  epididymitis  and  epididymo- 
orchitis  will  be  described  together,  as  they  are  practically 
the  same.  The  patient  begins  to  complain  of  pain  in  the 
testicle,  and  a  dragging,  aching  sensation  in  the  iliac  fossa 
and  groin  which  extends  down  the  cord  into  the  testis. 

There  is  a  rise  in  temperature,  often  accompanied  by 
chilly  sensations  or  a  well-marked  chill,  which  is  followed 
by  a  feeling  of  general  malaise.  As  the  inflammation  in  the 
epididymis  and  testicle  increases,  all  of  the  above  symptoms 
become  more  marked,  the  temperature  sometimes  going  to 
105°  F. ;  the  ])ain  in  the  testicle,  groin,  and  lumbar  region, 
which  may  e\en  run  up  into  the  kidney,  becomes  so  great 
that  the  patient  has  to  lie  down,  supporting  the  scrotum 
with  his  hand.  The  intensity  of  these  symptoms  varies 
greatly  in  different  individuals,  some  being  compelled 
to  go  to  bed,  while  others  are  up  and  about,  attending  to 
their  ordinarv  duties.    The  scrotum  is  hot,  red,  and  edema- 


KI'IDIhYMITlS   AND   lil'l l>l l)Y MO  Oh'CIIITIH 


tons.  'J'lic  epididymis,  cilJicr  in  p;irt  or  in  whole,  is  enhirj^ed, 
liiird,  und  e.\((uisit.ely  tender;  if  I  Ik;  testicle  he  in\'ol\-ed, 
it  also  is  very  painful,  firm,  ;ind  <i;reiitly  enlarK<'d. 

There  may  be  an  acute  hydrocele,  which  f;i\es  a  sense 
of  fluctuation  and  which  may  be  transilluminated.  The 
entire  cord  is  sometimes  i)ainful  and  thickene-fl,  and  can  b(; 
felt  as  far  up  as  the  ring  (acute  funiculitis). 


Fig.  27. — Author's  "  liridgc"  for  an  acutely  inflamed  testicle. 
(Author's  case.) 

The  duration  of  the  attack  depends  on  the  treatment, 
and  wdiether  the  epididymis  only  or  epididymis  and  testicle, 
be  involved. 

Treatment. — The  patient  should  be  put  to  bed,  given 
a  brisk  cathartic  and  have  the  general  treatment  for  acute 
posterior  gonorrhea.  The  scrotum  is  supported  by  a  band 
of  zinc  oxide  plaster  (see  Fig.  27),  three  or  four  inches  wide, 
which  passes  beneath  the  scrotum  to  each  thigh,  care  being 
taken  to  have  the  thighs,  legs,  and  inner  borders  of  the 
feet  close  together  before  applying  the  plaster.     If  there  is 


74       COMPIJCATIOXS  OF  POSTERIOR  GONORRHEA 

imicli  hair  on  the  tliiglis  it  should  he  sliaxcd  oil'  to  prevent 
j)ain  when  the  jjlaster  is  renioxed. 

The  serotuni,  supj)orted  as  above  described,  is  surrounded 
with  absorbent  gauze,  which  is  kept  saturated  day  and 
uiuht.    with    cold    lead-water;    or    a    satiu'ated    solution    of 


Fig.  28. — Author's  dressing  for  subacute  or  chronie  epididymo-orchitis. 
(Author's  case.) 


aluminum  acetate,  or,  in  some  cases,  a  20  per  cent,  guaiacol 
ointment  spread  on  gauze.  This  dressing  should  envelop 
the  entire  scrotum  and  extend  u])  into  the  groin  on  the 
aftected  side.  Over  this  should  be  placed  an  ice-cap,  Avhich 
must  be  removed  for  a  few  minutes,  every  hour  or  two, 
to  prevent  too  great  a  chilling  of  the  tissues. 


EPIDIDYMITIS  AND   HI'l DIDY MO  OliCJI ITIH         7b 

When  the  iwnU)  inlhiiiiniutory  syinj)torns  Ikiac  siihsidcd, 
iis  ii  result  of  the  above  treatment,  an  oliitrneiit  of  20  \h:v 
cent.  ichtJiyol  is  spread  over  the  scrotum,  which  is  then  snr- 
ronnded  l)y  a  hiyer  of  lint  or  non-absorlx'nt  cotton,  over 
which  is  phiced  a  piece  of  oiled  silk  or  I'uhber  tissue,  tlic 
whole  dressinf^  beiii^  kept  in  ])osition  b.y  a  snug  susi>eiisory 
bandage.  (See  Fig.  28.)  The  patient  is  allowed  to  get  up 
when  the  local  pain  and  tenderness  have  disappeared.  If 
there  is  very  marked  hydrocele,  great  relief  can  often  be 
afforded  by  aspiration  of  the  fluid,  great  care  being  taken 
not  to  wound  the  testicle,  or  to  infect  the  sac. 

Of  late  years  some  surgeons  have  advocated  the  operative 
treatment  of  acute  epididymitis  devised  by  Hagner.  This 
consists  of  exposure  of  the  epididymis,  by  an  incision  through 
the  overlying  scrotum,  followed  by  longitudinal  incision 
through  the  capsule  or  by  multiple  puncture  of  it  with  a 
good-sized  straight  needle  or  bistoury.  In  the  author's 
experience  the  operation  offers  no  advantage  over  the 
treatment  outlined  above;  in  a  large  series  of  parallel  cases 
the  pain  and  temperature  were  relie^'ed  more  rapidly 
and  the  time  spent  in  bed  was  considerably  less  in  those 
patients  that  were  treated  by  the  more  conservative,  non- 
operative  method.  If  true  abscess  of  the  epididymis  can 
be  demonstrated  the  pus  should  be  e^'acuated  by  free  incision 
and  the  cavity  irrigated  and  drained. 

The  induration  in  the  epididymis,  which  is  the  result 
of  the  inflammatory  process,  may  sometimes  be  reduced 
by  the  constant  use  of  20  per  cent,  ichthyol,  compound 
iodin,  or  50  per  cent,  mercurial  ointment.  The  use  of  the 
Oudin  high-frequency  current,  applied  to  the  testis  and 
epididymis  will  sometimes  assist  in  the  absorption  of  the 
exudate,   which,   if   left   untreated,    may   result   ui   partial 


7()        COMPLICATIONS  OF  POSTERIOR  GONORRHEA 

and  even  complete  sterilit\',  it"  both  epididynies  have  been 
invoK'ed.  In  tlie  hitt(M-  case  implantation  of  the  \as,  cnt 
through  a  short  distance  above  the  epididymis,  directly 
into  the  testis  itself,  as  advocated  by  ]\Iartin,  w  ill  sometimes 
])crinit  of  the  ])assage  of  spermatozoa  into  the  ejacnlate, 
thus  relic\"in<;'  the  ])atient's  sterility. 


SEMINAL  VESICULITIS. 

By  seminal  vesiculitis  or  spermatocystitis  is  meant  an 
inflammation  of  the  seminal  vesicles,  which  may  be  either 
acute  or  chronic.  It  may  occur  at  any  time  during  the 
course  of  the  disease.  The  inflammation  ])asses  directly 
from  the  floor  of  the  j^osterior  urethra  through  the  common 
ejaculatory  duct  to  either  one  or  both  ^'esicles. 

The  symptoms  of  acute  seminal  yesiculitis  are  i)ractically 
the  same  as  those  of  acute  posterior  urethritis  or  acute  pros- 
tatitis, the  patient  having  frequent  and  painful  urination 
with  vesical  and  even  rectal  tenesmus.  There  may  be 
painful  nocturnal  pollutions  stained  with  blood.  The 
patients  usually'  complain  of  a  feeling  of  fulness  just  within 
the  anus  or  in  the  perineum.  In  severe  cases  there  is  more 
or  less  fever,  accompanied  by  a  feeling  of  general  malaise. 

The  diagnosis  is  arrived  at  by  making  a  rectal  examination, 
when  the  vesicle  or  vesicles  can  be  felt  as  hot,  swollen,  tender 
bodies  situated  jtist  beyond  the  base  of  the  prostate  and  ruji- 
ning  upward  and  outward  (Fig.  25). 

For  this  examination,  the  patient  should  be  standing  up, 
with  the  trunk  bent  at  right  angles  to  the  thighs,  the  heels 
about  a  foot  apart,  and  the  palms  of  the  hands  resting  on  the 
seat  of  a  chair.     The  index-finger  is  used  for  examination 


SEMINAL   VESICULITIS  11 

;uul    slioiild    he    w(;ll    iiiioiiitcd    with    vasclin    iind    c(t\crc(l 
witli  a  thin  rubber  fiiif^er-tij)  or  f^Ioxc. 

The  treatment  is  the  same  as  that  lor  acute  jn-ostatitis 
and  posterior  urethritis,  to  which  the  reader  is  referred. 

Should  the  inflammation  j^o  on  to  abscess-formation, 
as  is  rarely  the  case,  the  ])ati('nt  must  be  anesthetized,  put 
in  the  lithotomy  jjosition,  and  the  y)us  evacuated  by  a 
vertical  or  semilunar  incision  tJu-ouf^h  the  perineum  just 
in  front  of  the  anus,  and  the  abscess  cavity  drained,  great 
care  being  taken  not  to  wound  the  urethra  or  rectum. 
In  a  good  many  cases  the  process  can  be  relieved  b}-  massage 
of  the  vesicle,  by  which  the  pus  is  expressed  into  the  urethra; 
operation  should  not  usually  be  resorted  to  until  this 
procedure  has  been  given  a  trial. 

The  steps  in  the  operation  are  given  in  the  section  dealing 
with  the  treatment  of  chronic  seminal  vesiculitis. 

Chronic  seminal  vesiculitis  may  follow  the  acute  form, 
or  be  caused  by  the  extension  backward  of  a  chronic  posterior 
urethritis  or  prostatitis. 

The  symptoms  of  chronic  seminal  vesiculitis  are  varied 
and  differ  greatly  in  different  indi\-iduals,  some  complaining 
that  they  are  becoming  impotent,  others  that  they  have 
nocturnal  pollutions  and  premature  ejaculations,  both  of 
which  may  be  blood-stained.  These  conditions  may  or  may 
not  be  associated  with  a  mucoid  or  mucopurulent  urethral 
discharge,  which  varies  greatly  at  different  times.  Some 
complain  of  a  sense  of  weight  and  fulness  in  the  rectum  and 
perineum,  while  others  are  absolutely  free  from  these  sensa- 
tions, the  only  symptom  of  the  disease  being  a  cloudy  urine 
with  flakes  and  slight  discharge  at  the  meatus.  Some 
patients  have  constant  and  greatly  increased  sexual  desire, 
with  perhaps  little  relief  after  intercourse. 


78  .    COMPLICATIONS  OF  POSTERIOR  GONORRHEA 

Tin-  syiiij)t()ins  of  cliroiiic  scniiiial  wsiculitis  aiv  so  similar 
to  thoso  of  chronic  i)rostatitis  and  posterior  urethritis  that  a 
correct  diagnosis  can  only  be  arrived  at  by  making  a  careful 
rectal  examination,  as  described  in  the  acute  form.  Wiien 
diseased,  the  vesicle  or  vesicles  may  often  be  plainly  felt 
by  the  finger,  running  uj)  and  out  from  the  base  of  the  pros- 
tate gland.  On  tJie  other  Jiand,  the  ])resence  of  a  chronic 
gonorrheal  arthritis,  ^vhich  resists  all  treatment,  or  the 
persistence  of  other  symptoms  of  gonorrhea  over  long 
periods  of  time  without  improvement  are  often  the  only 
indications  on  which  the  diagnosis  of  chronic  vesiculitis 
may  be  made. 

For  routine  treatment  the  vesicle  or  vesicles  can  ])e 
thoroughly  massaged  about  once  a  week,  and  the  patient 
given  the  regular  treatment  for  chronic  posterior  urethritis 
and  prostatitis,  the  details  for  which  will  be  found  fully 
described  in  Chapters  V  and  VII . 

In  a  certain  number  of  cases  which  do  not  respond  to 
this  treatment  Fuller  and  others  have  resorted  to  incision 
and  drainage  of  the  vesicles  by  the  perineal  route.  The 
technic  for  approaching  the  vesicles  differs  according  to  the 
choice  of  the  operator. 


URETHROCYSTITIS. 

Urethrocystitis,  either  acute  or  chronic,  is  not  an  uncom- 
mon complication  of  posterior  gonorrhea,  or  urethritis,  being 
caused  b}'  an  extension  backward  of  the  inflammatory  process 
from  the  posterior  urethra  into  the  bladder.  As  a  rule,  the 
inflammation  is  limited  to  the  mucous  mem})rane  for  an  inch 
or  so  surrounding  the  vesical  orifice  of  the  lu-ethra,  as  may 


UUKTII  liOCYSTl  TIS  70 

l)('  seen  hy  (\ys(<),sc()|)ic  cxiiiiiiiijit  ion,  tlic  iiuk'oii  ,  iiiciiilnniic 
ovc^r  the  trigone  being  reddened  iiiid  ((Iciniiloiis.  Il,  may 
extend,  however,  and  involve  the  ciiliic  hhiddcr  siirrncc, 
thus  constituting  a  true  cystitis. 

The  symptoms  of  acute  urethrocystitis  are  rnqiicnt  ;iiid 
painful  urination,  vesical  tenesmus,  and  in  severe  f;ases, 
terminal  hematuria.  In  short,  they  are  practically  the 
same  as  those  of  acute  posterior  gonorrhea  or  urethritis, 
except  perhaps  that  they  are  more  persistent  and  severe  in 
character,  the  patient  also  complaining  of  a  constant  deep- 
seated  pain  over  the  bladder,  which  is  intensified  at  the  close 
of  micturition. 

If  in  these  cases  we  employ  the  two-  or  three-glass  test,  the 
urine  in  all  of  the  cylinders  will  be  cloudy  from  pus  and 
mucus,  but  especially  so  in  the  second  or  third  cylinders, 
which  may  also  contain  blood  from  the  congested  mucous 
membrane  of  the  deep  urethra  and  vesical  neck.  This 
hematuria  may,  occasionally,  be  so  severe  that  the  urine, 
which  is  usually  acid  in  these  cases,  may  be  rendered  neutral, 
or  even  alkaline  in  reaction  by  the  blood  and  pus. 

As  the  inflammation  passes  into  the  chronic  stage  the  above 
sj^mptoms  all  become  much  less  marked  and  in  some  cases 
even  almost  disappear.  As  a  general  rule,  these  patients 
complain  of  an  uncomfortable  feeling  after  urination,  as  if 
the  bladder  were  not  emptied,  and  of  a  disagreeable  desire 
to  strain  out  the  last  drops  of  urine;  in  short,  ihev  have 
mild  vesical  tenesmus.  If  after  urination  a  soft  catheter  is 
passed  to  the  bladder  it  will  draw  a  drachm  or  so,  or  even 
more,  of  retained  or  residual  urine,  the  result  of  the  congested 
and  thickened  condition  of  the  mucous  membrane  about  the 
vesical  orifice,  which  prevents  the  bladder  from  emptying 
itself  normally. 


so       COMPLICATIONS  OF  POSTERIOR  COXORRHEA 

Treatment. — In  the  acute  stage  of  urethrocystitis  tlie  patient 
should  he  kept  very  quiet,  or  in  hcd,  with  hot  apjjhcations 
over  the  hladder  and  on  the  ])erineuni.  Hot  sitz  baths 
and  hot  rectal  irrigations  of  saline  solution  afford  great  relief. 
All  instrumentation  of  the  urethra  must  be  susi)ended, 
the  patient  put  on  a  light,  nutritious,  and  non-irritating 
diet,  and  the  urine  kept  bland  by  means  of  the  following 
prescription: 

R — Fid.  ext.  trit.  repens, 

Fid.  ext.  uvae  ursi.,  aa     5iss 

Potass,  citrat.,  .oij-iij 

Aq.,  ad      5iv — M. 

Sig. —  3J  in  water  one  hour  after  meals  and  during  the  night. 

Tenesmus,  if  severe,  may  have  to  be  controlled  by  the 
judicious  use  of  opium  or  morphin,  either  in  suppository, 
internally,  or  by  hypodermic  injection. 

The  patient  may  drink  any  bland  water,  liut  not  in  too 
great  quantity. 

It  is  very  important  to  keep  the  bowels  nio\ing  freely,  and 
for  this  purpose  we  may  employ  a  little  calomel  or  any  good 
cathartic  pill. 

When  as  a  result  of  the  above  treatment  the  acute  inflam- 
matory symptoms  begin  to  subside,  it  is  time  to  commence 
irrigation  of  the  deep  urethra  and  bladder,  using  at  first 
warm  boracic  acid  solution,  and  later  permanganate  of 
potash  or  silver  nitrate.  The  technic  for  this  treatment 
will  be  found  fully  described  in  the  sections  devoted  to 
chronic  urethritis,  and  to  these  the  reader  is  referred. 

CYSTITIS. 

Gonorrheal  cystitis,  by  which  is  meant  a  suppurati\'e 
inflammation  of  the  entire  vesical  mucous  membrane,  is  an 


CYSTJT/.^  SI 

extremely  nirc  coinplicatioii  of  .'iciih;  or  clironic  |)o.st(;rior 
gonorrhea.  It  may  l)e  eitlicr  acut(;,  subjiciitc  or  nlironic  in 
character,  and  is  usually  the  result  of  a  niixcfl  inlcction,  in 
which  the  gonococcus  plays  little  or  no  jjart. 

The  symptoms  of  acute  gonorrheal  cystitis  consist  of 
pain  over  the  bladder  and  sacrum  and  increased  frequency 
in  urination,  which  is  very  painful,  especially  at  its  close, 
and  is  followed  by  more  or  less  tenesnnis  and  sometimes 
blood.  These  patients  are  really  sick,  having  a  rise  of 
pulse  and  temperature  and  a  feeling  of  general  malaise  and 
lassitude. 

As  the  process  becomes  subacute  and  then  chronic,  all 
of  the  above  s,ymptoms  lose  their  severity  and  intensity', 
the  patient  complaining  of  some  pain  and  urgency  in  urina- 
tion, and  uneasy  sensations  in  and  about  the  bladder  and 
pelvis. 

The  urine,  during  the  acute  stage,  is  normal  in  odor 
and  acid,  though  rendered  opaque  by  pus,  tissue  elements 
and  bladder  epithelium.  In  a  well-established  chronic, 
case,  however,  it  becomes  foul  and  alkaline,  with  coagidation 
of  the  pus  into  ropy  and  gelatinous  masses,  owing  to  bacterial 
decomposition.  In  any  stage,  if  it  is  passed  into  three  glasses, 
all  will  be  cloudy  with  pus  and  shreds,  especially  the  last. 

Treatment. — During  the  acute  stage  of  the  disease  the 
patient  should  be  kept  in  bed,  and  on  a  light  nutritious  diet, 
avoiding  alcohol  and  coffee,  and  anything  that  is  highly 
spiced  or  seasoned  that  may  in  any  way  irritate  the  urinary 
tract.  Water  may  be  taken,  but  not  in  too  large  quantities. 
The  bowels  must  be  moved  freely  once  in  twenty-four  hours 
by  means  of  any  reliable  cathartic  pill.  Hot  applications 
over  the  bladder  and  on  the  perineum  give  much  relief, 
as  do  also  the  hot  sitz  bath  and  rectal  irrigation  of  hot 
6 


82       COMPLICATIONS  OF  POSTERIOR  GONORRHEA 

saline  solution,  taken  once  or  twice  daily.  If  the  pain 
and  tenesmus  are  Aery  severe,  we  may  hare  to  resort  to  the 
guarded  use  of  opium  or  morphin,  or  belladonna,  either  by 
suppository,  internally,  or  by  liypodermic  injection. 

The  urine  must  be  kept  bland  by  the  administration  of 
citrate  of  potasJi,  either  alone  or  combined  with  hyoscyamus, 
uva  ursi,  and  triticum  repens,  as  given  in  the  formula  for 
acute  posterior  urethritis  and  urethrocystitis. 

As  a  result  of  this  treatment  the  majority  of  cases  pass 
quite  rapidly  into  the  subacute  and  chronic  stage,  when  the 
patient  is  allowed  to  be  up  and  about,  and  given  a  more 
liberal  diet.  Alkalies  can  now  be  discontinued  and  the 
l^atient  given  boric  acid  in  full  dose,  as  in  the  following 
formula : 

IJ — Ac.  boric,  3ijss 

Tr.  hyoscyami,  3ij 

Aq.,  ad      gviij — M. 

Sig. — ^5ss  one  hour  after  meals. 

If  in  spite  of  the  above  treatment  the  urine  still  remains 
alkaline  or  neutral  in  reaction,  a  normal  acidity  can  usually 
be  obtained  by  the  administration  of  urotropin  or  helmitol 
in  full  dose. 

Xow  is  the  time  to  begin  bladder  irrigations,  given  very 
gently  and  carefully  by  means  of  a  small  catheter  and  four- 
ounce  hand  syringe  in  the  following  manner:  The  patient 
urinates  and  then  lies  comfortably  on  his  back;  the  surgeon 
then  passes  a  small  soft-rubber  or  silk  catheter,  properly 
cleaned  and  lubricated  (see  Fig.  17),  into  the  bladder, 
and  gently  injects  a  warm  and  non-irritating  medicated 
solution,  until  the  patient  has  a  desire  to  m-inate  or  feels 
uneasy  in  any  way,  when  the  fluid  is  innnediately  allowed  to 
escape  through  the  catheter.    This  may  be  repeated  a  few 


URETEIUT/S,   l')'MLrr/S,   AND  I'Y I'lLOM I'U'II lUTI S     K\ 

times,  tJu;  catheter  Ix'in^-  fiiuilly  witliditiun,  leaving  sev(;ral 
ounces  of  solution  in  IIk;  hhiddcr,  wiiieji,  as  the  i)atient 
voids  it,  medicates  the  mucous  meml)rane  of  his  prostatic 
urethra,  which  was  the  starting-point  and  cause  of  tlie 
cystitis,  so  that  in  tliis  manner  we  treat  not  only  the  hladdcT, 
but  also  the  entire  lengtli  of  tJic  urctln-jil  canal. 

As  a  rule,  the  irrigations  are  given  once  daily,  hegiiming 
with  warm  boric  acid  or  salt  solution,  and  later  zinc  sulphate 
and  alum  solution  (1  to  3000  up  to  1  to  1000)  followed,  still 
later,  by  potassium  permanganate  (1  to  15,000  up  to  1  to 
2000),  and  finally  by  nitrate  of  silver  solution,  beginning 
with  1  to  20,000,  and  increasing  slowly  and  guardedly  up 
to  1  to  5000  or  even  stronger. 

Complicating  prostatis,  seminal  vesiculitis,  or  stricture 
should  receive  appropriate  treatment. 

URETERITIS,  PYELITIS,   AND  PYELONEPHRITIS. 

Among  the  very  rare  and  infrequently  encountered 
complications  of  posterior  gonorrhea,  or  more  accurately 
speaking,  of  gonorrheal  cystitis,  may  be  mentioned  ureteritis, 
pyelitis,  or  pyelonephritis;  the  infection  traveling  upward 
from  the  bladder  to  the  kidney  by  way  of  the  lu-eters;  or 
being  carried  to  these  organs  through  the  lymphatics  or 
blood  stream.  The  diagnosis  of  which  kidney  is  invohed 
is  greatly  aided  by  catheterization  of  the  ureters  through 
the  cystoscope.  These  complications  are  generally  ob- 
served in  persons  who  have  had  antecedent  vesical  disease, 
or  in  whom  there  is  some  obstruction  or  hindrance  to  the 
free  outfloM'  of  urine  from  a  urethral  stricture  or  prostatic 
enlargement.    As  a  general  rule,  but  one  kidne^'  is  in\oh-ed. 


CHAPTER  VI. 

CHRONIC  ANTERIOR  AND  POSTERIOR 
GONORRHEA. 

Chronic  gonorrhea,  also  commonly  known  as  gleet,  is 
spoken  of  as  chronic  anterior  gonorrhea,  when  the  disease 
is  situated  scnnewhere  in  the  anterior  urethra;  as  chronic 
posterior  gonorrhea,  when  in  the  posterior  urethra;  as 
chronic  anteroposterior  gonorrhea,  when  the  entire  length 
of  the  urethra  is  involved;  and  as  chronic  urethrocystitis 
when  the  disease  has  invaded  the  bladder  to  a  limited 
extent  around  the  urethral  orifice. 

A  gonorrhea  is  called  chronic  when  it  has  existed  for 
more  than  eight  or  ten  weeks,  and  has  lost  all  of  its  acute 
inflammatory  manifestations. 

The  lesions  of  chronic  gonorrhea  consist  of  a  small  round- 
cell  infiltration  into  the  submucous  connective-tissue  layer, 
and  a  chronic  catarrhal  inflammation  of  the  mucous  mem- 
brane itself,  whose  normal  cylindrical  epithelium,  as  a  result 
of  the  gonorrheal  process,  has  been  destroyed  in  patches, 
and  as  healing  occurs,  replaced  by  the  flat  pa^•ement  A'ariety, 
thus  leaving  the  canal  in  a  more  or  less  thickened  and  rigid 
condition. 

The  causes  of  chronic  gonorrhea  are  many,  prominent 
among  them  being  sexual  and  alcoholic  indulgences  during 
the  declining  stage,  patients  thinking  themselves  cured 
at  that  time  as  they  see  no  discharge  at  the  meatus,  and 
therefore  stopping  treatment  et  this,  the  most  important 
period  in  their  disease. 


CHRONIC  ANTERIOR  GONORRHEA  85 

(lOiiorrlicii.  is  also  a|)1,  to  run  a.  clircniic  course  in  dchilitatcd, 
run-down,  and  ancniic;  subjects,  and  in  tliose  wjio  will  not, 
or  cannot,  take  sufficient  rest  or  proper  treatment  in  tlie 
acute  inflammatory  stage  of  tJie  disease. 

Tlie  numerous  so-called  abortive  methods,  with  strong 
injections,  retrojections,  irrigations,  and  endoscopic  appli- 
cations during  the  acute  infiainmatory  stage,  are  very  liable 
to  leave  the  patient  with  a  tJiickened  urethra,  congested 
prostate,  and  a  clyonic  disciuirge  tJiat  is  most  rebellious  to 
treatment. 

Chronic  congestion  and  inflammation  of  the  prostate 
gland,  as  a  result  of  gonorrhea  and  sexual  errors  and  excesses, 
is  a  frequent  cause  of  chronic  urethral  suppuration,  and  should 
therefore  not  be  overlooked  in  the  treatment  of  these  cases. 

Seminal  vesiculitis  is  undoubtedly  the  etiological  factor  in 
some  cases  of  chronic  gonorrhea,  but  is  rare,  as  compared 
to   chronic   affections   of   the   prostate. 

An  abnormally  small  meatus,  or  a  condition  of  phimosis, 
associated  with  balanoposthitis,  may,  from  the  irritation 
they  produce,  be  important  factors  in  the  continuation  of  a 
chronic  urethritis. 

Uncured  preputial,  peri-  or  paraurethral  folliculitis,  or 
infection  of  any  of  the  glands  or  follicles  opening  into  any 
part  of  the  urethra  (Cowper's  glands,  the  glands  of  Littre, 
and  the  crypts  of  JNIorgagni),  may  cause  the  lightening  up, 
or  prolongation  of  a  gonorrhea;  therefore  these  structures 
should  receive  due  consideration  and  treatment. 

Warty  and  polypoid  growths  in  the  urethra  may,  from  the 
irritation  they  occasion,  keep  up  a  urethral  discharge  for 
a  long  time.  They  maj^  be  diagnosticated  by  endoscopic 
examination,  which  may  be  employed  in  chronic  and  re- 
bellious cases. 


86     CHRONIC  ANTERIOR  AND   POSTERIOR  GONORRHEA 

Urethral  stricture,  resulting  from  a  previous  gonorrhea 
or  a  trauniatisni,  may  sometimes  complicate  and  keep  up 
a  chronic  urethral  discharge,  and  must  therefore  not  he 
forgotten  in  the  examination. 

CHRONIC  ANTERIOR  GONORRHEA. 

The  symptoms  of  chronic  anterior  gonorrhea  are  \ery 
\ariahle:  In  some  cases  tlie  lips  of  the  meatus  arc  glued 
together  in  the  morning  by  the  discharge  which  has  accumu- 
lated in  the  urethra  during  the  night;  in  others  there  is  a 
variable  amount  of  mucopurulent,  mucoid,  or  serous  dis- 
charge at  the  meatus,  which  is  usually  increased  after  sexual 
or  alcoholic  indulgence.  In  still  other  cases  there  is  no 
gluing  of  the  meatus,  the  only  symptom  of  the  chronic 
inflammation  being  flakes  and  shreds  in  the  urine.  In  the 
majority  of  cases  there  is  no  visible  discharge  at  the  meatus 
during  the  day,  as  the  urethra  is  so  frequently  flushed  out 
by  the  stream  of  urine.  Patients  often  complain  of  a  dribbling 
of  a  few  drops  of  urine  after  each  act  of  urination;  this  is 
due  to  a  loss  of  elasticity  of  the  urethral  walls  as  a  result 
of  the  chronic  catarrhal  and  exudative  inflammation  into 
the  submucous  connective-tissue  layer,  which  leaves  them 
in  a  more  or  less  rigid  condition,  and  unable  to  empty  them- 
selves normally. 

The  Thompson  two-glass  test,  for  the  differential  diagnosis 
of  chronic  anterior  and  chronic  posterior  gonorrhea,  should 
not  be  relied  on,  as  it  is  only  applicable  to  acute  cases  asso- 
ciated with  much  suppuration. 

The  so-called  gonorrheal  flakes  and  shreds  consist  of 
moist  scales  made  up  of  pus  and  epithelial  cells,  held  together 
by  fibrin  or  mucus;  they  are  situated  upon  spots  of  con- 


CHRONIC  POSTERIOR  GONORRHEA  87 

gestion,  erosion,  ;iih1  superficial  ulceration  iilonji;  tlic  iirctlirnl 
walls,  which  mark  the  localities  where  the  gonorrheal  process 
has  become  localized.  These  congested,  eroded,  or  ulcerated 
patches  form  the  lesions  of  chronic  gonorrhea,  and  are 
most  commonly  found  in  the  bulbous  urethra,  as  this  j)()rtion 
of  the  canal  is  large  (33  to  36  F.),  has  no  capsule,  is  sur- 
rounded by  erectile  tissue,  and  being  dependent,  drains 
poorly;  all  of  the  above  conditions  greatly  favoring  a  long- 
continued  inflammatory  process. 

When  the  stream  of  urine  strikes  the  edges  of  these  moist 
scales  it  rolls  them  up,  and  they  therefore  appear  as  threads 
or  shreds  suspended  in  the  urine,  which  may  be  either 
turbid  or  clear. 

As  healing  advances  the  pus  cells  disappear,  the  flocculi 
being  made  up  entirely  of  epithelial  cells,  which,  when 
the  case  is  cured,  also  vanish,  leaving  a  clear,  transparent 
urine. 

In  a  general  way  it  may  be  stated  that  the  threads  or 
shreds  from  the  anterior  urethra  are  usually  long  and  thread- 
like in  character,  while  those  from  the  posterior  urethra  are 
lumpy  and  ragged  in  appearance,  although  too  much  reliance 
must  not  be  placed  on  these  distinctions.  iMicroscopically 
both  kinds  are  found  to  be  composed  of  the  same  elements. 
The  presence  of  spermatozoa,  which  may  sometimes  be 
discovered  entangled  in  their  meshes,  is  an  aid  in  deciding 
on  their  place  of  origin,  though  not  absolutely  conclusive. 

CHRONIC  POSTERIOR  GONORRHEA. 

Although  chronic  posterior  gonorrhea  may  sometimes 
occur  alone,  it  is  accompanied  in  the  vast  majority  of  cases 
by  a  chronic  bulbous  urethritis,  as  well  as  bv  some  chronic 


8S     CHRONIC  AXTERIOR  AND   POSTERIOR  GONORRHEA 

uri'tlirocystitis,  which  in  turn  may  he  associated  with 
prostatitis,  or  c\on  seniiiial  \"csiciiHtis,  which  conditions 
iiiiist  not  he  i'orijotten  when  phinnin<>;  treatment. 

In  these  cases  there  is  more  or  less  increased  frequency  of 
urination  with  a  f(>elinu'  of  (hscomfort  cither  at  the  beginning 
or  termination  of  the  act,  and  sometimes  a  ver\'  sHght 
discharge  at  the  meatus,  particuhirly  in  the  morning.  The 
urine  may  he  clear,  turbid,  or  cloudy,  and  contains  shreds 
from  the  posterior  urethra,  which,  as  a  rule,  sink  rapidly 
to  the  bottom  of  the  glass.  In  some  cases  there  are  frequent 
nocturnal  ])()llutions  which  may  be  bloody;  in  others 
premature  ejaculation,  associated  with  dull,  painful  sensa- 
tions in  the  region  of  the  prostate  and  periiieuin.  These 
sexual  manifestations  are  due  to  the  congested  and  inflamed 
condition  of  the  posterior  urethra,  prostate  gland,  and 
possibly,  of  the  seminal  vesicles. 

The  above  symptoms  vary  widely  in  different  individuals, 
in  some,  well-marked  and  constant,  in  others,  very  slight  and 
only  brought  into  activity  by  alcohf)lic  and  sexual  indul- 
gences, which  cause  a  congestion  of  the  posterior  urethra  and 
prostate,  with  a  lightening  up  of  the  dormant  inliammation. 

If,  as  is  usually  the  case,  the  patient  also  has  an  anterior 
gonorrhea,  a  more  marked  discharge  will  usually  be  present 
at  the  meatus. 


CHAPTEll  VII. 

TREATMENT  OE  C11JK)NJC  ANTERIOJi  AND 
POSTERIOR  GONORRHEA. 

Before  l)eginning  any  form  of  treatment,  we  should  first 
ascertain  tlie  number,  duration,  severity,  and  complications 
of  the  preceding  attack  or  attacks  of  gonorrhea,  as  this 
information  will  shed  much  light  on  the  patient's  present 
condition,  and  also  aid  greatly  in  the  selection  of  a  proper 
plan  of  treatment. 

In  all  cases  of  chronic  gonorrhea,  the  urine  should  be 
carefully  examined.  Its  reaction,  the  amount  of  pus, 
epithelial  cells,  and  bacteria,  and  the  composition  of  the 
shreds  should  be  ascertained.  Any  excess  of  phosphates, 
carbonates  and  urates  should  be  noted. 

If  urination  is  painful  the  patient  should  take  any  of  the 
alkaline  mixtures  alluded  to  abo^'e  and  drink  freely  of 
any  bland  water.  Coffee,  chocolate  and  cocoa  and  alcohol 
are  to  be  stopped  until  the  case  is  well  under  control,  when 
they  may  be  resumed  in  moderation.  The  diet  should  be 
nutritious,  but  simple,  the  patient  avoiding  all  highly 
spiced  and  seasoned  dishes.  As  soon  as  the  pain  or  smarting 
on  urination  ceases,  great  benefit  will  be  derived  in  many 
cases  from  the  use  of  the  antiblennorrhagics. 

All  sexual  excitement  must  be  strictly  guarded  against,  as 
it  causes  urethral  and  prostatic  congestion  and  thus  retards 
a  cure,  as  does  also  excessive  exercise. 


90     CHRONIC  ANTERIOR  AND  POSTERIOR  GONORRHEA 

If  the  iiriiu'  is  cloudy  from  i)iis  (pyuria)  as  \\c'll  as  gonor- 
rlieal  flakes  and  threads,  it  is  best  to  begin  with  retrojections 
or  irrigations,  which  consist  of  throwing  into  either  the 
anterior  or  posterior  urethra  se^•eral  t)unces  of  a  warm 
medicated  fluid.  If,  liowever,  the  urine  is  clear,  or  as  a 
result  of  the  aboNC  measures  tlie  pus  disappears  and  nothing 
but  tln-eads  remains  in  the  clear  urine,  it  is  tlien  time  to 
stop  retrojections  or  irrigations  and  substitute  for  them 
instillations,  which  consist  of  a  drachm  of  a  concentrated 
medicated  solution,  injected  into  the  canal,  the  technic  for 
which  will  be  described  in  detail  farther  on. 

If  chronic  gonorrhea  is  complicated  by  stricture  of  the 
urethra,  prostatitis,  seminal  vesiculitis,  an  abnormally 
small  meatus,  or  phimosis  associated  with  balanoposthitis, 
these  conditions  should  receive  appropriate  treatment  which 
will  be  found  fully  described  under  these  separate  headings, 
to  which  the  reader  is  referred. 

TREATMENT  OF  CHRONIC  ANTERIOR  GONORRHEA. 

The  general  rules  just  described  having  been  minutely 
carried  out,  the  anterior  urethra  is  treated  in  the  following 
manner,  either  by  irrigations  or  instillations,  according  to 
the  condition  of  the  urine. 

Irrigations  should  be  given  as  follows:  The  patient 
passes  his  urine  in  order  to  flush  out  the  canal;  then  a 
small,  sterile  soft-rubber  or  bulbous  \voven-silk  catheter 
(see  Figs.  15  and  lo),  well  lubricated,  is  passed  very 
gently  into  the  bulb  of  the  urethra. ,  A  large  hand-syringe 
(Fig.  2)  is  then  attached  to  the  end  of  the  catheter  by  means 
of  a  coupler  (Fig.  2),  and  the  warm  medicated  fluid  injected 
slowly  and  gently  into  the  bulb  of  the  urethra,   beyond 


TliEATMKNT  OF  CJIIlONlC  ANTERIOR  GONORRIINA     01 

whicli  it  (Iocs  not.  pjiss  on  ;i,ccotiiil,  of  jJic  compressor  iii-<;t  licic 
muscle,  bill  flows  I'orw ;i,i(l  iiiul  escapes  ;it  the  iii(;atns. 

In  this  iiiiumer  all  ol"  the  diseased  areas  in  tlie  anterior 
portion  of  tlu;  canal  are  brought  into  direct  contact  with 
the  medicated  sohition. 

The  irrigations  may  he  given  daily  or  every  other  day, 
according  to  the  results  obtained,  which  can  be  ascertained 
by  the  patient's  symptoms  and  sensations,  and  also  the 
cond|ition  of  the  urine,  which  should  be  examined  before 
each  treatment. 

On  the  alternate  days  the  patient  can  use  an  ordinary 
hand-injection,  if  so  desired,  provided  it  does  not  cause 
irritation,  which  it  sometimes  does.  The  amount  of  solution 
used  at  each  sitting  varies  from  four  to  eight  ounces,  the  fluid 
should  always  be  warm,  and  thrown  in  with  the  utmost  care 
and  gentleness. 

For  irrigation  solutions  we  use  the  following  stock  formulae 
in  the  order  given  and  manner  described: 

Solution  I. 
I^ — Alum,  crud., 

Zinc,  sulphat.,  aa  1.00 

Aq.  destillat.,  500.00 — M. 

Sig.^-Add  one-half  (^)  of  an  ounce  of  this  solution  to  seven  and  a  half 
{7\)  ounces  of  warm  boiled  water,  and  inject.  Increase  strength  from  day 
to  day  until  equal  parts  of  solution  and  water  are  used,  or  even  stronger, 
if  so  desired. 

Solution  II. 
I^ — Potass,  permanganat.,  1.00 

Aq.  destillat.,  .500.00 — M. 

Sig. — Add  one-quarter  (J)  of  an  ounce  of  this  solution,  to  seven  and  three- 
quarters  (7J)  ounces  of  warm,  boiled  water,  and  give  an  irrigation  every 
day  or  every  other  day,  increasing  the  strength  slowly  up  to  1  to  1000 
(1  to  16,000  to  1  to  1000). 

Solution  III. 
^ — Argent,  nitrat.,  1.00 

Aq.  destillat.,  500.00 — M. 

Sig. — Use  in  precisely  the  same  manner  as  the  second  solution,  increasing 
the  strength  very  slowly,  as  the  silver  nitrate  is  liable  to  cause  severe  pain 
and  irritation  if  used  too  strong  (1  to  16,000  to  1  to  1000). 


92     CURONIC  ANTERIOR  AND  POSTERIOR  GONORRHEA 

Tlie  i'ollowinji;  t;il)lc'  will  l)i'  t'oiiiul  \-en-  ('onvciiicnt  in 
makiiiu'  ii])  tlu'  i)rnnan'i;inatt"  or  siKcr  solutions: 

//(  an  S  (iz.  (jraduaie:  sfoch  sal.  (/  to  500). 

3ij    of  solution  equals  1  to  10,000 

3ss  of  solution  equals  1  to    S.OOO 

5j     of  solution  equals  1  to    4,000 

5ij    of  solution  equals  1  to    2,000 

3iij  of  solution  equals  1  to    1,300 

5iv  of  solution  equals  1  to    1,000 

If,  at  about  the  end  of  the  tenth  or  tweU'th  week  of  tlie 
disease,  the  patient  still  complains  of  a  dribbling  of  urine 
from  the  meatus  after  urination,  good  results  will  often 
be  obtained  by  the  judicious  use  of  warm,  medium-sized 
steel  sounds  passed  to  the  triangular  ligament  a})out  once  a 
week,  and  left  in  the  uretlira  for  about  a  minute;  the  pressure 
which  the  sound  exerts  helps  to  restore  the  lost  elasticity 
of  the  urethral  walls,  and  in  that  way  cures  this  troublesome 
and  disagreeable  symi)t()m.  In  the  author's  experience 
sounds  are  greatly  to  be  preferred  to  any  of  the  \arious 
dilators  in  use. 

If,  after  using  the  abo\e  irrigations  in  the  manner  described 
the  urine  is  rendered  clear  but  still  contains  shreds  and 
flakes,  it  is  advisable  to  give  the  patient  instillations  of 
nitrate  of  silver  in  the  anterior  urethra.  This  method  is 
fully  described  in  the  next  section. 

TREATMENT    OF    CHRONIC    POSTERIOR    GONORRHEA. 

Before  proceeding  to  discuss  the  treatment  of  chronic  posterior 
f/onorrhea  it  will  he  well  to  emphasize  the  fact  that  in  the  vast 
majority  of  cases  of  (/onorrhcal  infection  the  entire  length 
of  the  urethra  and  the  bladder  base  become  involved  in  the 


TREATMENT  OF  CIIIIONIC  POSTEHIOR  GONORRHEA      O.'i 

yroccsa.  Under  these  circumstances,  of  course,  Ixdli.  the  ante- 
rior and  'posterior  urethras  must  be  treated  in  order  /o  ohtaiu  a 
cure.  Great  care  must  therefore  he  taken  in  malciiKj  a  diafjnosis 
of  anterior  Involvement  only. 

The  general  lines  of  treatment  described  on  page  80 
having  been  instituted,  the  posterior  urethra  and  a  limited 
area  of  the  bladder  should  be  irrigated  by  retrojection. 

The  patient,  having  urinated  in  order  to  cleanse  the  canal, 
lies  down,  with  head  and  shoulders  elevated  and  muscles 
relaxed,  and  a  small,  sterile,  soft-rubber  catheter,  properly 
lubricated,  is  gently  passed,  so  that  its  eye  lies  just  within 
the  bladder,  which  will  be  shown  to  be  the  case  by  the  escape 
of  a  drachm  or  so  of  retained  urine.  In  some  exceptional  cases 
it  will  be  found  impossible  to  pass  a  soft-rubber  catheter 
beyond  the  compressor  urethrae  muscle.  For  these  cases 
we  can  substitute  a  No.  10  French  woven-silk  instrument, 
which,  although  more  rigid  than  the  rubber  one,  is  flexible 
and  less  liable  to  cause  irritation  and  compressor  spasm 
than  the  metal  instruments  whicJi  are  sometimes  recom- 
mended for  this  purpose.  The  much-talked-of  and  over- 
estimated spasm  of  the  compressor  urethra  muscle  is,  as  a 
rule,  caused  by  rough,  rapid,  and  unskilful  instrumentation, 
and  will  rarely,  if  ever,  be  encountered,  provided  the  surgeon 
is  gentle  and  uses  flexible  catheters  in  preference  to  metal 
ones. 

A  four-ounce  syringe  (Fig.  2)  is  attached  to  the  catheter 
by  means  of  a  coupler  with  stopcock,  and  the  warm  medicated 
fluid  thrown  slowly  and  gently  into  the  bladder.  When 
the  syringe  is  empty  the  stopcock  is  turned  off,  the  syringe 
uncoupled,  refilled,  and  more  fluid  injected  until  the  bladder 
feels  full,  or  the  patient  complains  of  a  desire  to  urinate, 
when  the  catheter  is  slowlv  withdrawn  into  the  bulbous 


94     CHRONIC  ANTERIOR  AND  POSTERIOR  GONORRHEA 

portion  and  the  entire  anterior  urethra  irrigated.  The 
jiatient  now  stands  up  and  passes  the  medicated  fluid, 
which,  having  already  acted  on  the  base  of  the  bhidder, 
washes  out  the  posterior  lu'ethra,  and  flowing  through  the 
anterior  urethra,  distends  it  as  it  rushes  out,  and  in  this 
manner  medicates  all  of  the  congested,  eroded,  or  ulcerated 
spots  and  patches  along  the  canal. 

The  solutions  used  must  always  be  warm  and  increased 
very  slowlj'  in  strength,  especially  the  permanganate  of 
potash  and  nitrate  of  silver  solution,  which,  if  too  strong, 
will  set  up  intense  vesical  and  rectal  tenesmus,  which  may 
last  for  several  hours.  The  fluid  should  always  be  injected 
with  a  f(,ur-ounce  hand-syringe,  as  with  it  we  know  the 
exact  amount  of  solution  thrown  in,  the  resistance  off'ered 
by  the  bladder,  and  the  force  used;  whereas,  if  an  irrigator 
or  fountain  syringe  were  employed,  none  of  the  above 
valuable  information  could  be  obtained,  and  more  or  less 
damage  might  be  done. 

The  amount  of  fluid  used  at  each  sitting  A-aries,  a  good 
average  being  about  eight  ounces,  although  many  bladders 
will  not  hold  more  than  from  one  to  four  oimces  at  flrst;  this 
is  due  to  irritability  of  the  posterior  urethra,  with  more  or 
less  contraction  of  the  bladder,  which  has  been  produced 
by  the  frequent  calls  to  expel  the  urine  during  the  acute 
attack;  this  irritability  subsides  rapidly  under  the  treatment, 
and  patients  frequently  speak  of  the  comfort  they  experience 
after  the  first  few  irrigations. 

If,  in  spite  of  the  above  treatment,  carefully  carried  out, 
the  urine  does  not  clear  up  promptly,  then  the  prostate,  semi- 
nal ^•esicles,  and  ampullated  ends  of  the  vasa  deferentia  must 
be  examined  per  rectum,  and  if  found  affected,  treated  as 
described  in  the  sections  devoted  to  these  subjects. 


TREATMENT  OF  CHRONIC  I'OSTEIUOJl  (lONORRJIEA     05 

If,  after  having  used  the  irrigations  or  retrojectioiis,  the 
urine  clears  up,  but  still  contains  gonorrheal  threads  and 
tissue  elements,  it  is  advisable  to  change  our  plan  of  treat- 
ment by  using  small  amounts  of  concentrated  sohitions; 
these  are  called  instillations,  and  are  given  in  the  following 
manner  (Fig.  29):  The  patient,  having  urinated,  lies  (hnvn 
or  stands  before  the  surgeon,  who  passes  a  small,  sterile, 
soft-rubber  or  silk  catheter,  as  before,  into  the  posterior 


Fig.  29. — Urethral  instillation.      (Original.) 


urethra,  if  posterior  urethritis  or  urethrocystitis  exists,  or  into 
the  bulb  of  the  urethra,  if  there  is  only  an  anterior  urethritis 
to  deal  with,  and  by  means  of  the  author's  instillation 
syringe  (Fig.  3),  throws  in  about  a  drachm  of  a  solution  of 
nitrate  of  silver.  When  the  posterior  urethra  is  involved, 
half  the  syringeful  is  injected  into  it  and  the  rest  into  the 
anterior  urethra  as  the  catheter  is  withdrawn.  Before  inject- 
ing the  solution,  any  urine  retained  in  the  bladder  must  first 
be  drawn  off,  in  order  not  to  decompose  the  medication. 


90     CHEOXIC  ANTERIOR  AND   POSTERIOR  GONORRHEA 

The  strength  of  the  nitrate  of  silver  sokitions  used  should 
run  from  1  to  10,000  for  tlie  first  injcctidii,  up  to  1  to  1000 
or  1  to  500,  or  even  stronger. 

These  instillations  should  be  repeated  daily  or  every  other 
day,  according  to  the  results  obtained  and  the  strength 
of  the  solution  used.  In  some  rebellious  cases  we  may  be 
comi)elled  to  increase  the  strength  of  the  silver  solution 
up  to  1  to  250,  or  even  1  to  100;  this  should  be  done  very 
slowly  and  carefully,  and  the  instillations  given  at  longer 
intervals;  our  guide  in  these  cases  being  the  condition  of  the 
urine,  which  should  be  examined  at  each  ^'isit.  In  the  same 
manner  we  may  sometimes  advantageously  use  o  to  G  per 
cent,  sulphate  of  thallin  solution;  as  a  rule,  howe\er,  nitrate 


Fig.  30. — Silk  bulbous  instillation  catheter. 


of  silver  is  the  most  efficacious  of  all,  and  if  intelligently 
used  will  produce  a  cure. 

In  some  cases,  where  unusual  thickening  and  edema  of 
the  mucous  membrane  makes  a  certain  amount  of  pressure 
on  the  tissues  and  dilatation  desirable,  we  may  substitute 
for  the  ordinary  rubber  or  silk  catheter  a  bulbous  silk 
catheter,  as  shown  in  Fig.  30. 

The  specially  constructed  metal  instruments  or  drop 
catheters,  which  are  sometimes  recommended  for  instillations, 
should  never  be  employed  on  account  of  the  irritation  and 
trauniatisni  that  they  are  liable  to  produce,  even  in  skilful 
hands.  If  the  surgeon  fails  to  enter  the  deep  urethra  with 
soft-rub})er  and  silk  catheters  it  is  ])roof  ])ositi\e  that  he  is 
either  very  unskilful,  or  that  the  parts  are  in  a  far  too  irritable 


TREATMENT  OF  J'llUONK!   I'O^TKIilOll   (lONOIiUII EA     \)1 

and  sensitive  eondition  lor  any  l\iiHl  of  local  nntliral  iiicdi*  a- 
tion.  'I'lie  rit/iiiaiiii  (Iroj)  catheter,  wliicli  consists  of  a 
tlnck-vvallcd  silvcT  catlictcr  with  capillary  horc,  and  a  ^lass 
and  hard-rubber  syringe,  is  the  histrument  usually  employed 
by  those  who  are  opposed  to  soft-rubber  instruments  for 
urethral   medication. 

The  use  of  the  endoscope  (urethroscope)  in  the  treatment 
of  chronic  gonorrhea  is  frequently  of  service  in  those  cases 
which  have  resisted  the  different  forms  of  treatment  already 
described. 

The  endoscope  can  only  be  employed  to  ad\aiitage  in 
certain  selected  cases  in  the  chronic  stage  of  the  disease, 
and  by  one  who  is  accustomed  to  the  appearance  of  the 
urethral  walls,  both  in  their  normal  and  diseased  states. 
By  its  aid  we  can  examine  with  the  eye  the  entire  length 
of  the  anterior  urethra,  recognize  polypoid  or  warty  growths, 
areas  of  infiltration,  congestion  and  erosion,  diseased  follicles, 
false  passages,  stricture,  impacted  stones,  etc.,  and  treat 
them  locally  by  topical  applications  of  various  kinds. 

It  must  be  remembered,  however,  that  the  endoscope  is 
an  instrument  of  reserve,  and  should  never  be  employed 
in  a  routine  or  careless  manner,  as  its  frequent  passage 
through  the  urethral  canal  causes  more  or  less  irritation, 
distention,  and  congestion  of  this  sensitive  and  highly 
vascular  mucous  membrane. 

It  should  never  be  used  in  the  prostatic  portion  of  the 
urethra,  where  its  relatively  sharp  edge,  by  pressure  on 
the  verumontanum  and  the  orifices  of  the  ejaculatory  and 
prostatic  ducts,  causes  more  or  less  trauma  and  bleeding, 
as  a  result  of  which  the  author  has  not  infrequently  seen 
epididymitis,  prostatitis,  and  even  abscess  of  the  prostate. 

Should  we  desire  to  examine  this  region  visually,  the  close- 


98     CHRONIC  ANTERIOR  AND  POSTERIOR  GONORRHEA 

vision  urethrocystoscope  is  the  instrument  of  choice,  for 
with  it  we  can  not  only  reduce  trauma  to  a  minimum  but 
also  get  a  much  clearer  and  less  distorted  ^■iew  of  tlie  struct- 
ures in  the  posterior  urethra. 

For  general  endoscopic  work  the  most  useful  ty])es  of 
instrument  are  those  constructed  on  the  principle  of  the 
Luy  urethroscope  and  the  instrument  devised  by  the 
author. 

In  the  Luy  instrument  the  light  consists  of  a  small, 
"cold"  lamp,  carried  on  a  staf}'  of  such   length  that  the 


Fig.  31. — Liiy's  urethroscope. 


lamp  rests  just  within  the  distal  end  of  the  endoscopic 
tube  (Fig.  31).  This  instrument  gives  an  excellent  view 
of  the  urethral  walls,  as  the  tube  is  slowly  withdrawn,  but 
lias  the  disadvantage  tliat  the  lamp  may  easily  become 
covered  with  secretion  or  blood,  thus  cutting  ofl'  the  illumina- 
tion, and  that  the  lamp  is  somewhat  in  the  way  of  applicators 
and  other  instruments. 

To  obviate  these  objections  and  to  supply  an  instrument 
with  unobstructed  field,  in  which  the  operator  can  see 
the  lesions  while  treating  them,  I  have  devised  the  present 


TREATMENT  OF  CIIIIONK'  I'OSTIiinOlt  COSOUHII ICA      00 

urethroscope,  wliicli  cuii  he  used  eitlier  in  the  aiiLfTior  c>r 
posterior  urethra,  and  even  in  the  bladder,  where  the  ureteral 
orifices  can  he  found  and  cathetcrizcd,  small  stones  or  foreign 
bodies  removed,  and  the  nmcous  mcinhrane  clearly  seen. 


Fig.  32.— Author's  operating  and  examining  urethroscope. 


The  tubes  for  the  anterior  urethra  are  5  inches  long  and 
those  for  the  posterior  urethra  6f  inches,  but  can  be  length- 
ened or  shortened  according  to  the  requirements  of  the  case, 
and  made  in  any  caliber.  The  proximal  ends  of  the  obtu- 
rators  and  tubes  are  milled  so  as  to  give  the  operator  a 


100     CHRONIC  ANTERIOR  AND  POSTERIOR  GONORRHEA 

firm  hold,  and  flattened  above  and  below  to  prevent  their 
rolling  when  laid  down.  The  little  lamp  consists  of  a  carbon 
filament  in  front  of  which  is  a  planoconvex  "collecting" 
lens,  which  gathers  and  projects  the  rays  to  the  distal  end 
of  the  tnbe  where  the  field  is  seen  in  brilliant  illumination. 
The  lamp  is  held  in  a  metal  collar  outside  of  the  tube  so 
that  it  does  not  encroach  on  the  field,  is  not  in  the  way 


^=^g^ 


.^^m=. 


@= 


WAPPLER  E.  M.     CO.   INC     NEW  YORK 


Fig.  33. — Instruments  for  operating  endoscope. 

of  applicators,  examining  or  operating  instruments,  and 
cannot  be  soiled  and  obscured  by  blood,  secretions,  or  the 
lubricant.  If  air  distention  is  required,  an  air-tight  cap  with 
magnifying  lens  is  slipped  over  the  proximal  end  of  the 
collar  and  the  urethra  gently  and  carefully  dilated  by  slowly 
compressing  the  little  bulb,  which  forces  air  down  the  tube, 
where  it  can  be  retained  by  shutting  off  the  stopcock. 
Water  distention  may  also  be  used,  if  so  desired.    For  simple 


WHEN  IS  aONORRIIEA    dUliKI)  101 

examination,  treatment.,  or  "  liil^nralion,"  a  manjm'fyiii^  lens 
is  attached  to  tlie  collar  hy  a  slender  rod  w  liieli  allows  of  the 
use  of  appHcators  and  any  kind  of  instrnments  under  din-et 
visual  inspection. 

The  method  of  usinu;  the  instrument  is  as  follows:  'J'he 
patient,  having  emptied  his  bladder,  lies  down  on  the 
operating  table,  his  thighs  supported  1)\'  proper  foot-rests 
or  two  ordinary  stools.  The  largest  tube  that  will  enter  the 
meatus  with  ease  is  then  selected,  cleansed,  and  lubricated 
and  passed  slowly  and  gently  into  the  bulb  of  the  urethra  (in 
rare  cases  into  the  prostatic  urethra),  the  obturator  carefully 
withdrawn,  and  the  light  turned  on;  the  urethral  walls  are 
then  seen  bulging  into  the  lumen  of  the  tube,  which  being 
slowly  withdrawn,  gives  a  clear  and  distinct  picture  of  the 
entire  canal  from  behind  forward.  As  diseased  areas  are 
discovered  they  may  be  touched  wdth  concentrated  solutions 
of  silver  nitrate  or  copper  sulphate  by  means  of  wooden 
applicators  wrapped  with  absorbent  cotton,  which  has  been 
dipped  in  the  medicated  solution.  Polypoid  and  warty 
growths  can  be  easily  removed  by  means  of  a  delicate 
snare  used  through  the  tube  or  by  fulguration  with  the 
Oudin  or  d'Arsonval  high-frequency  spark. 

WHEN  IS  GONORRHEA  CURED? 

Having  considered  the  treatment  of  gonorrhea  and  its 
complications,  the  important  question  now  arises:  When  is 
the  disease  cured,  or  at  what  time  does  the  patient  cease  to 
be  infectious?  In  order  to  answer  these  questions  intelli- 
gently we  must  examine  the  patient's  morning  urine,  passed 
in  our  presence,  for  several  successive  mornings,  and  if  it  is 
clear  and  contains  neither  pus  nor  gonorrheal  shreds;  that  is, 


1(V2     CHROXIC  ANTERIOR  AND  POSTERIOR  GONORRHEA 

if  if  he  pcrfirtli/  iioninil  mi  rcpralcd  in'icruscopic  ('X(uii'niat'n)US, 
we  know  that  the  urt'tlitTal  lesions,  at  least,  have  been 
cured.  If,  on  the  other  hand,  there  are  shreds,  which  under 
the  microscope  are  found  to  consist  of  pus  and  e])ithehal 
cells,  whether  they  contain  gonococci  or  not,  we  know  that 
the  urethral  lesions  are  still  uncured,  and  that  the  secretion 
may  be  infectious.  If  the  shreds  consist  of  epithelial  cells 
alone,  they,  of  course,  in  themselves,  may  not  be  dangerous; 
but  even  these  patients  must  be  warned  not  to  have  sexual 
relations,  and  adN'ised  to  take  a  proper  course  of  local  treat- 
ment. In  order  to  ascertain  that  there  is  no  lurking  trouble 
in  the  })rostate  gland,  seminal  vesicles,  or  ampullated  ends 
of  the  vasa  deferentia,  as  a  result  of  posterior  gonorrhea, 
the  patient  should  pass  all  of  his  urine,  and  then  have  8 
to  10  ounces  of  warm,  sterile  water  injected  into  his  bladder. 
The  prostate,  vesicles,  and  vasa  deferentia  are  then  examined 
and  massaged  by  a  finger  in  the  rectum.  The  material 
appearing  at  the  meatus  is  ^ecei^'ed  in  a  sterile  glass  graduate 
and  kept  for  examination;  the  patient  now  passes  the  fluid 
in  his  bladder,  which  washes  out  any  remaining  secretion 
that  has  been  expressed  into  the  urethra;  the  sediment 
from  this  fluid  and  the  material  caught  at  the  meatus  are 
examined  microscopically  and  cultures  taken,  and  if  the 
findings  show  disease,  this  must  be  treated  as  already 
described  imder  urethritis,  prostatitis,  and  seminal  vesic- 
ulitis. The  examiner  must  be  familiar  Avitli  the  normal 
secretions  of  the  prostate,  vesicles,  and  ampulla",  so  as  not 
to  err  in  his  microscopic  fintlings.  One  cannot  be  too  guarded 
in  giving  an  opinion  on  this  subject,  and  should  therefore 
make  the  above  examinations  in  a  most  thorough,  con- 
scientious, and  careful  manner,  an()  warn  })atients  against 
matrimony  or  sexual  relations  until  they  are  absolutely  cured. 


WHEN  IS  CONOR  nil  MA   CURED  10.'^) 

The  follicles  in  tlu;  iiit(;<i;uiii(U]t  of  tlic  jxiiis,  between  the 
two  layers  of  the  prepuce,  and  in  the  lips  of  the  meatus,  and 
also  all  of  the  glands  that  open  into  the;  anterior  urethra 
should  be  carefully  examined,  in  order  to  ascertain  that  they 
are  free  from  the  gonorrheal  process.  The  presence  of  a  posi- 
tive fixation-test  for  the  gonococcus  in  the  absence  of  other 
symptoms,  should  also  be  considered  proof  that  the  disease 
is  not  cured,  provided  we  bear  in  mind  the  fact  that  a  positive 
test  will  often  be  obtained,  even  in  cured  cases,  for  two 
or  three  months  after  an  acute  gonorrhea. 


CHAPTER  VIII. 
GONOUUIIEAL  OPHTHALMIA. 

GoxoRRiiEAL  ophthalmia  in  the  adult  is  caused  by  the 
accidental  transference  of  gonorrheal  pus  from  the  genitals 
to  the  eyes  by  means  of  the  fingers,  dressings,  or  towels, 
and  is  tlierefore,  strictly  speaking,  not  a  complication  of 
gonorrhea,  but  rather  an  accidental  infection. 

In  the  newly  born  the  infection  occurs  during  parturition, 
from  the  gonorrheal  pus  in  the  mother's  vaginal  tract. 

While  the  infection,  in  the  adult,  is  comparatively  rare, 
it  is,  unfortunately,  by  no  means  uncommon  in  young 
infants,  in  whom,  under  the  name  of  ophthalmia  neona- 
torum, it  has  been  responsible  for  thousands  of  cases  of 
so-called  congenital  blindness. 

Symptoms  usually  appear  within  a  few  hours  after  infection 
and  consist  of  redness  and  swelling  of  the  conjunctiva, 
increased  lachrymation,  and  a  collection  of  mucus  at  the 
inner  angle  of  the  eye,  accompanied  by  intense  itching  and  a. 
feeling  as  if  foreign  bodies  were  beneath  the  lids. 

The  conjunctivitis  soon  imolves  both  of  the  lids,  as  well 
as  the  ocular  mucous  membrane,  and  is  associated  with  a 
profuse  purulent  secretion,  which  flows  out  from  between  the 
intensely  red  and  greatly  swollen  lids.  The  patient  is  at 
this  time  unable  to  open  the  eye,  or  eyes,  voluntarily. 

The  foregoing  manifestations  are  accompanied  by  intense 
pain  in  the  eye-ball,  forehead,  and  temi)le,  with  rapid  pulse, 
rise  of  temperature,  and  general  malaise. 


tui<:atmi<:nt  lor, 

The  ])r()};ii()sis  is  jilwiiys  \l,va\v,  and  depends  greatly  upon 
the  time  tlic  patient  aj)i)li('S  for  treatJiient,  wlicther  one  or 
both  eyes  are  attacked,  and  also  the  extent  nnd  situation  of 
the  ulceration. 

It  is,  at  l)est,  one  of  the  most  serious  complications  of 
gonorrhea,  and  as  it  may  result  in  either  partial  f)r  ef)mi)lete 
blindness,  the  prognosis  must  always  be  made  in  a  most 
guarded  and  careful  manner. 

Treatment. — The  treatment  may  be  divided  into  pro})hyl- 
actic  and   curative. 

Prophylaxis  in  the  adult  consists  of  scrupulous  cleanliness, 
the  avoidance  of  transferring  pus  to  the  eyes,  and  the  im- 
mediate burning  of  all  dressings  which  have  been  soiled  by 
the  secretions  of  the  urethral  tract. 

In  the  newborn  infant  infection  can  be  pre^•ented,  in 
99  per  cent,  of  the  cases,  by  careful  cleansing  of  the  eyes 
and  the  instillation  into  each  eye,  as  soon  as  the  child  is  born, 
of  two  drops  of  a  2  per  cent,  solution  of  nitrate  of  silver,  as 
first  advocated  by  Crede. 

Should  infection  occur,  however,  the  patient,  as  soon 
as  the  first  symptoms  appear,  is  put  to  bed  in  a  well-venti- 
lated room  and  two  competent  nurses  are  employed,  one 
for  day  and  the  other  for  night. 

If  only  one  eye  is  aflfected,  the  sound  one  is  covered  with  a 
shield  to  prevent  its  infection;  this  shield  is  made  of  two 
pieces  of  rubber  plaster,  one  four  and  the  other  four  and 
one-half  inches  square,  with  their  adhesive  surfaces  in  contact, 
between  which,  in  a  hole  made  in  the  centre,  a  deeply  con- 
cave watch-glass  is  fastened;  through  this  glass  the  patient 
can  see  and  the  eye  be  inspected  by  the  physician;  the 
rubber  plaster  is  fastened  to  the  skin  about  the  eye,  and  its 
edges  sealed  with  collodion. 


106  GONORRHEAL  OPIITJIALMIA 

The  nurses  must  be  warned  of  tlie  danger  of  infection,  and 
told  how  to  avoid  it  by  keepino-  their  hands  and  nails  clean, 
anil  by  wearing  large,  plain-glass  si)eetacles  to  protect  their 
eyes  during  the  dressings  and  irrigations. 

The  eye  must  be  washed  out  day  and  night  with  a  3  per 
cent,  solution  of  cold  boric  acid  (made  with  distilled  water) 
as  often  as  any  secretion  accumulates,  and  in  the  intervals 
between  the  washings  the  eye  should  be  kept  coN'ered  with 
cold  cloths  (absorbent  gauze  or  sheet  lint)  taken  from  a 
block  of  ice,  and  changed  every  two  or  three  minutes;  these 
cloths  must  be  burned  as  soon  as  remo^•ed,  and  ncN'cr  used 
again. 

The  eye  is  flushed  out  by  means  of  an  irrigator,  held  high 
enough  to  allow  the  cold  boric  acid  solution  to  flow  out  in  a 
gentle  stream. 

From  the  onset  of  the  infection  well  up  to  the  declining 
stage  two  drops  of  a  2  per  cent,  solution  of  nitrate  of  silver 
should  be  dropped  into  the  eye  once  or  twice  in  twenty-four 
hours,  according  to  the  severity  of  the  inflammation;  the 
silver  nitrate  solution  being  applied  directly  after  a  boric  acid 
washing. 

If  the  cornea  becomes  involved,  instillations  of  a  sulphate 
of  atropin  solution  (gr.  ij  to  Sj)  should  be  employed  three 
times  daily,  and  the  nitrate  of  siher  stopped. 

Unless  the  attending  physician  is  very  familiar  with  diseases 
of  the  eye,  he  should  send  immediately  for  a  competent 
ophthalmic  surgeon,  as  faulty  treatment  will  often  result 
in  the  loss  of  either  one  or  both  eyes. 


c;hapter  tx. 

(lONORRHEAL  ARTHRITIS. 

Gonorrheal  rheumatism,  or  more  correctly  speaking, 
gonorrheal  arthritis,  is  a  common  and  always  serious 
complication  of  gonorrheal  infection.  The  disease  occurs  in 
both  men  and  Avomen,  but  is  most  frequently  observed 
in  the  former;  in  some  cases  it  accompanies  every  attack 
of  specific  urethritis,  but  in  others  only  one. 

While,  in  the  majority  of  cases  in  both  sexes,  it  follows 
gonorrheal  invasion  of  the  urethra,  it  may  also  complicate 
a  gonorrheal  ophthalmia,  iritis,  vulvovaginitis  or  gonococcic 
infection  of  other  structures.  This  complication  may  occur 
at  any  time  of  life,  from  infancy  to  old  age. 

In  men  it  usually  occurs  between  the  twentieth  and 
fortieth  years.  The  exciting  cause  of  the  disease  is  the 
gonococcus  and  its  toxins,  which  gain  access  to  the  general 
circulation,  and  are  thus  carried  to  the  joints  from  some 
local  focus  of  gonorrheal  infection. 

In  the  acute  cases,  when  the  joint-effusion  is  serous  or 
serofibrinous,  the  gonococcus  can  usually  be  found  in  the 
exudate  of  the  affected  articulation. 

In  the  subacute  and  clironic  cases,  however,  or  when  the 
exudate  is  seropurulent  or  purulent  in  character,  the  gono- 
coccus is  very  rarely,  if  ever,  found.  In  the  purulent  cases 
we  are  now  dealing  with  a  mixed  infection,  in  which  we  find 
a  large  variety  of  organisms,  among  which  may  be  mentioned 


lOS  cnxonmiEAL  arthritis 

the  staphylococcus,  streptococcus,  and  occasionally  the  colon 
hacillus.  A  single  ncgatl\'c  examination,  however,  is  not 
suflicient  to  settle  the  diagnosis,  as  a  second  or  later  one 
may  reveal  the  i)resence  of  the  gonococcns. 

It  is  very  difficult  to  state,  definitely,  how  often  gonorrheal 
arthritis  complicates  gonorrheal  infection. 

The  figures  given  l)y  diH'erent  investigators  vary  hctween 
I   ami    10  ])('r  cent. 

It  should  never  he  forgotten  that  the  diagnosis  of  gonor- 
rheal rheumatism  is  frequently  overlooked,  many  cases 
being  recorded  as  chronic  rheumatism,  rheumatoid  arthritis, 
arthritis  deformans,  rheumatic  gout,  etc.,  so  that  the  pro- 
portion is  probalily  much  higher  than  it  woukl  at  first  appear 
to  be. 

The  examination  of  am'  given  case  of  arthritis  therefore 
should  never  be  considered  complete  without  a  careful 
investigation  of  the  patient's  history  for  previous  gonococcic 
infections  and  a  thorough  search  for  the  presence  of  urethritis, 
vesiculitis,  prostatitis,  salpingitis,  or  vulvovaginitis. 

In  males  the  gonococci  usually  enter  the  circulation 
from  the  deep  urethra,  prostate,  and  seminal  vesicles. 

It  is  extremely  doubtful  whether  infection  of  the  joints 
ever  complicates  a  purely  anterior  urethritis. 

In  women  the  articular  involvement  usually  follows  a 
gonorrheal  endometritis  or  salpingitis. 

Trauma  and  ])revious  rheumatic  or  gouty  affections  of  tlie 
joints  are  predisj)()sing  causes. 

I'nder  trauma  we  must  include  not  only  direct  injury 
to  the  articulations,  but  also  rough  or  unskilful  treatment 
of  the  urethral  tract,  such  as  irrigation  of  the  urethra 
and  bladder  by  hydrostatic  pressure,  after  the  example  of 
Janet,  or  by  the  large  hand-syringe,  whereby  fluid  is  forced 


GONORRHEAL  AU.TIIRITIH  IO(J 

tlirongll  i\\V.  <'()Ill|)|-('SS()r  inusclc  ililo  the  deep  ii|-etlii;i  ;iimI 
bladder. 

The  piis,sii<>;(!  ol"  sounds,  urethroscopes  or  v\g\i\  iiistruuient.T 
in  the  acute  stiiji;e  of  the  disease,  and  the  use  of  unnecessarily 
strong  and  irritatin<!;  injections  must  also  he  inchidcd  under 
this  lieadinj;-,  as  any  of  these  i)rocedures  may  cause  the 
gonorrJieal  process  to  pass  rapidly  into  the  deep  urethra, 
prostate,  and  seminal  vesicles. 

The  invasion  of  the  joints  is  most  likely  to  occur  during 
the  first  few  weeks  of  an  acute  urethritis,  but  it  may  take 
place  at  any  time  and  in  any  stage  of  the  disease. 

None  of  the  articulations  are  exempt  from  attack,  but 
certain  of  them  appear  to  be  more  liable  to  infection  than 
others. 

In  order  of  frequency  those  most  often  invohed  are  the 
knee-,  wrist-,  ankle-,  finger-  and  toe-joints,  elbows,  hips, 
shoulders,  temporomaxillary,  and  sternoclavicular  articula- 
tions. 

It  is  worthy  of  note  that  temporomaxillary  arthritis  is 
much  more  frequently  gonorrheal  than  not,  and  that  its 
occurrence  should  always  lead  us  to  suspect  a  Xeisserian 
infection. 

The  number  of  joints  in\'olved  at  one  time  is  usually 
two  or  three,  but  infection  of  more  than  this  number  is 
not  infrequently  observed,  especially  when  the  smaller 
articulations,  such  as  those  of  the  fingers  and  toes,  are 
affected. 

The  onset  of  the  disease  may  be  either  gradual  and  mild 
or  sudden  and  acute. 

In  the  former  type  the  objecti\e  symptoms  are  few 
at  first;  the  patient  usually  complains  of  pain  in  one  or  more 
joints,  which  is  at  its  worst  in  the  morning,  on  arising, 


no  GONORRHEAL  ARTHRITIS 

and  accompanied  by  more  or  less  stiffness  of  tlie  affected 
articulations. 

As  the  patient  moves  about  the  i)aiii  and  stiffness  diminish, 
and  later  in  the  day  may  even  disappear  completely,  not  to 
return  until   the  next  morning. 

The  pain  may  be  sharp,  and  shift  from  one  joint  to  another, 
or  it  may  be  dull  and  stationary. 

In  many  cases  only  one  joint  at  a  time  will  give  symptoms, 
but  it  is  also  common  for  several  to  be  involved  at  once. 

^^'hile  at  first  there  is  little,  if  any,  change  in  the  external 
aspect  of  the  part,  sooner  or  later,  if  the  process  goes  on 
unchecked,  external  evidences  of  inflammation  begin  to 
appear;  there  is  more  or  less  effusion  into  the  joint  cavity, 
redness,  heat  and  periarticular  swelling  and  tenderness. 

Fever  is  rarely  a  prominent  symptom  in  these  cases, 
unless  an  exacerbation  occurs,  when  the  picture  changes 
to  that  of  the  second  or  acute  ^'ariety. 

In  this  type,  which  may  appear  suddenly  without  warning, 
or  which  has  been  preceded  by  some  of  the  symptoms 
described  above,  there  is  a  severe,  acute  arthritis,  appearing 
suddenly,  with  extreme  pain  and  a  temperature  which  may 
reach  102°  to  103°  F.,  or  more. 

The  joints  iinolved  are  exceedingly  painful,  hot,  and 
swollen,  and  their  function  is  completely  lost. 

The  skin  is  red  and  tender,  and  there  is  a  marked  and 
rapidly  increasing  effusion  into  the  articular  ca\ity. 

This  type,  which  in  many  of  its  aspects  closely  resembles 
acute  rheumatic  fever,  rarely  resohes  completely,  in  the 
manner  so  characteristic  of  the  latter  disease,  and  exhibits 
also,  as  docs  the  variety  first  described,  a  marked  tendency 
to  result  in  more  or  less  fibrous  ankylosis  of  the  ini])licated 
joint  or  joints. 


GONORRHEAL  ARTHRITIS  111 

The  fluid  obtained  by  aspiration  is  nsually  serous  and 
contains  gonococei. 

Rarely  it  may  beeome  seropurulent  or  purulent,  but  this 
is  usually  a  sign  of  the  oceurrence  of  a  mixed  infection, 
(staphylococcus,  streptococcus,  etc.). 

Whether  the  onset  of  the  disease  belongs  to  the  first 
or  to  the  second  of  the  types  above  described,  a  common 
and  distressing  result  is  the  appearance  of  a  stubborn, 
persistent  hydrarthrosis,  lasting  in  many  cases  for  weeks 
or  even  months. 

The  knee  is  the  articulation  most  likely  to  be  thus  impli- 
cated. 

Occasionally  both  knees  are  affected,  but  unilateral 
involvement  is  more  frequent. 

The  condition  is  characteristically  stationary  and  resistant, 
as  compared  to  acute  rheumatism,  where  the  inflammation 
shifts  from  joint  to  joint. 

In  those  cases  in  which  the  gonococei  attack  the  smaller 
articulations  the  condition  often  closely  resembles  a  poly- 
arthritis deformans.  The  joints  of  the  carpus  and  tarsus 
and  those  of  the  fingers  and  toes  are  the  ones  most  commonly 
involved,  especially  the  interphalangeal  articulations,  in 
which  case  the  inflammation  often  results  in  the  formation 
of  the  typical  "radish  finger"  of  the  French  authors. 

Atrophy  of  the  muscles  in  relation  to  the  aft'ected  joints 
is  common,  with  an  accompanying  falling  of  the  arches, 
when  the  feet  are  involved. 

The  diagnosis  is  to  be  made  on  the  existence  of  an  un cured 
gonorrhea,  and  the  finding  of  gonococei  in  the  secretions 
from  the  urethra,  prostate  or  vesicles;  the  small  number 
of  joints  involved,  the  chronicity  of  the  disease  with  evanes- 
cent   exacerbations,    the    extreme    tendency  to   ankylosis, 


112  GONORRHEAL  ARTHRITIS 

tlio  presence  of  a  positive  complement-fixation  test  for  the 
ijonococcus,  and  the  characteristic  resistance  to  the  usual 
antirheumatic  remedies. 

In  passing,  it  is  well  to  niciition,  as  frequent  acconipani- 
nuMits  of  ii'oiiorrlical  arthritis,  tenosynovitis,  myositis, 
especially  of  the  muscles  of  the  neck,  back  and  forearm, 
and  bursitis,  most  often  aU'ecting  the  burste  about  the 
tendo   Achilles   and    os   calcis. 

Isolated  patches  of  i)eriostitis,  especially  of  the  os  calcis 
and  Acrtebrje,  are  also  occasionally  observed. 

In  considering  the  treatment  of  gonorrheal  rheumatism 
it  must  never  be  forgotten  that  no  amount  of  local  joint 
treatment  will  of  itself  be  of  any  a\ail  unless  we  attack, 
coincidentally,  the  local  foci  of  infection  whence  fresh  su})plies 
of  gonococci  are  continually  fed  into  the  general  circulation. 

It  is  therefore  imperative  that  the  urethral  tract  and  the 
glandular  structures  in  anatomical  relation  with  it  should 
be  carefully  examined,  and  that  urethritis,  para-,  and  peri- 
urethritis, cowperitis,  ])rostatitis  or  seminal  vesiculitis, 
should  receive  appropriate  local  treatment,  with  irrigations, 
instillations,  prostatic  and  vesicular  massage,  hot  rectal 
irrigations  of  normal  saline  solution,  and  variously  medicated 
rectal  suppositories;  also  local  applications  through  the 
endoscopic  tube,  and  the  prompt  liberation  of  any  pus 
formation  in  the  periurethral  glandular  structures,  prostate, 
or  seminal  vesicles. 

Stric-tures  of  the  urethra  must  be  dealt  with  either  by 
gradual  dilatation,  or  by  internal  or  external  urethrotomy, 
depending  upon  their  consistence  and  situation  in  the  canal. 

The  urine  should  be  rendered  antiseptic  by  the  use  of 
urotropin  in  full  dosage,  and  the  patient  instructed  to 
drink  freeh'  of  Ijland  still  waters,  and  to  avoid  alcoholic 


aoNOiih'iiKA  L  A  urn  in  ris  1 13 

beverages  iiiid  nil  ;irli<'lcs  of  diet  lli;il  f;iii--c  iiiiiKiry  con- 
ceiitration  or  irritation. 

The  local  treatineiil  of  flic  joints  <l(])cn(|^  cntirdx  npon 
the  stage  of  tlie  disease  in  wliicli  tlie  |)atieMt  is  seen. 

During  the  acute  jx'riod  llic  idlVricd  joints  slionld  l)c  put 
completely  at  rest. 

The  patient  should  be  kept  as  (luiet  as  possible,  or  j>nt  to 
bed,  and  the  inflamed  joints  immobilized  by  appropriate 
splints;  the  use  of  cold  wet  dressings  of  aluminum  acetate, 
bichloride  of  mercury,  or  a  solution  of  lead  subacetate,  in 
conjunction  with  an  ice-bag,  is  indicated  for  the  relief  of 
pain  and  swelling.  Internal  medication  with  the  salicylates, 
aspirin,  pyramidon,  etc.,  is  sometimes  useful  in  alleviating 
the  pain,  but  these  drugs  have  absolutely  no  specific  action 
whatsoever. 

When  the  process  has  reached  the  subacute  or  chronic 
stage  it  is  time  to  begin  the  use  of  measures  designed  to 
restore  the  mobility  of  the  joint  and  to  pre^'ent  the  formation 
of  adhesions. 

Massage,  passive  and  active  mo\ements,  the  use  of 
superheated  dry  air,  baking  the  part  at  a  temperature  of 
250°  to  350°  F.,  the  therapeutic  incandescent  lamp,  and  the 
Oudin  high-frequency  electric  current  are  all  very  useful 
at  this  time. 

Some  benefit  may  also  be  derived  from  local  applications 
of  ichthyol,  methyl  salicylate,  or  compoinid  iodin  ointments, 
and  a  firm  pressure  bandage. 

Of  utmost  importance  in  this  stage  of  the  disease  is  the 
use  of  gonococcic  vaccines  and  sera. 

These  should  be  autogenous  whene^•er  possible,  but  very 
satisfactory  results  can  also  be  obtained  from  the  use  of  the 
usual  stock  preparations. 


114  GONORRHEAL  ARTHRITIS 

TJie  dosage  sliould  begin  with  about  25,000,000  organisms, 
and  tlie  injections  be  repeated,  Avitli  constantly  increasing 
doses,  every  three  to  six  days,  according  to  the  reaction 
and  the  results  obtained. 

Antigonococcus  serum  has  not  yielded  as  good  results,  in 
my  hands,  as  vaccine,  but  it  is  occasionally  very  beneficial, 
and  should  therefore  not  be  forgotten. 

The  large  number  of  cases  of  gonorrhea  in  which  the 
seminal  vesicles  have  apparently  acted  as  the  local  foci  of 
infection  has  led  Fuller  and  others  to  resort  to  perineal 
incision   and   drainage   of  these   structures. 

Some  very  brilliant  residts  have  been  reported  following 
this  procedure  but  the  operation  should  never  be  advised 
until  the  above  methods  of  treatment  ha\'e  been  given  a 
fair  and  sufficient  trial,  as  the  exposure  and  drainage  of  the 
vesicles  is,  at  best,  an  operation  of  some  magnitude. 

The  use  of  Bier's  hyperemia  is  sometimes  of  service  in 
chronic  and  subacute  cases,  but  in  the  author's  experience 
it  has  proved   of  doubtful   value. 

Occasionally  in  rebellious  cases  of  hydrarthrosis  which  have 
resisted  strapping  and  the  other  measures  described  above, 
it  may  be  necessary  to  resort  to  aspiration  of  the  joint  under 
the  most  rigid  aseptic  precautions. 

In  the  rare  cases  in  which  the  arthritis  goes  on  to  sup- 
puration, immediate  arthrotomy  and  drainage  is  imperative, 
but  the  prompt  and  intelligent  application  of  the  methods  of 
treatment  outlined  above  will,  as  a  rule,  render  the  adoption 
of  tliis  measure  unnecessary. 


CHAPTER  X. 

STUKTURK  OF  THE  UU>7JMIKA. 

In  order  that  the  reader  may  clearly  understand  what 
stricture  is,  and  how  to  detect  and  treat  it  properly,  it  is 
necessary  at  this  point  to  devote  a  few  lines  to  the  anatomy, 
length,  shape,  and  so-called  "caliber"  of  the  urethra. 

The  male  urethra  is  a  collapsed  canal  or  a  continuous  closed 
valve,  whose  surfaces  or  walls  are  always  in  contact,  except 
during  urination,  ejaculation,  and  the  passage  of  instruments. 
It  extends  from  the  meatus  urinarius  externus  to  the  bladder, 
which  it  joins  at  a  right  angle. 

It  is  made  up  of  three  layers,  an  internal  or  mucous  layer, 
a  middle  or  submucous  connective-tissue  layer,  and  an 
external  or  muscular  layer,  which  in  turn  consists  of  circular 
and  longitudinal  fibers  running  from  the  bladder  to  the 
meatus,  the  circular  or  ring-shaped  fibers  being  situated 
outside  of  the  longitudinal  ones.  In  overdistention  of  the 
canal  with  examining  instruments  the  circular  fibers  may  be, 
and  have  been,  frequently  mistaken  for  true  stricture,  and 
the  patient  subjected  to  much  harmful  and  unnecessary 
treatment. 

The  mucous  membrane  of  the  urethra  is  shining  in  appear- 
ance, yellowish-pink  in  color,  arranged  in  longitudinal  and 
small  transverse  folds,  and  covered  with  flat  pavement- 
epithelium  for  about  the  first  quarter  of  an  inch  to  one  inch 
of  its  length,  beyond  which  it  is  of  the  columnar  variety  as 
far  as  the  bladder. 


116  STRICri'RE  OF   THE    URETHRA 

The  portion  of  the  canal  which  is  contained  in  the  cori)us 
spongiosum  extends  from  the  meatus  urinarius  externus  to 
the  penoscrotal  junction,  where  it  joins  the  bulbous  portion; 
it  is  known  as  the  penile  or  pendulous  urethra.  On  the  roof 
or  upper  surface  of  the  penile  urethra,  about  one-half  to  three- 
quarters  of  an  inch  from  the  meatus,  is  the  lacuna  magna, 
into  the  orifice  of  which,  although  bounded  by  valve-like 
reduplications  of  the  mucous  membrane,  the  tips  of  whale- 
bone filiform  bougies  are  apt  to  pass  during  urethral  exami- 
nations. 

Situated  principally  in  the  roof  or  upper  surface,  but  also 
in  the  floor  or  lower  surface  of  the  canal  for  about  the  first 
three  or  four  inches  of  its  length,  are  the  mucous  follicles  or 
glands  of  the  urethra,  with  their  orifices  opening  directly 
toward  the  meatus;  these,  if  dilated,  may  also  engage  the 
tips  of  small  examining  instruments. 

The  bulbous  portion  of  the  canal  extends  from  the  peno- 
scrotal junction  to  the  anterior  layer  of  the  triangular  liga- 
ment, and  is  surrounded  bj^  the  erectile  tissue  of  the  bulb  of 
the  corpus  spongiosum  and  the  accelerator  urina^  muscle. 

Opening  directly  on  its  floor  are  the  two  orifices  of  Cowper's 
ducts,  the  glands  themselves  being  situated  between  the 
anterior  and  posterior  layers  of  the  triangular  ligament,  and 
in  the  substance  of  the  compressor  urethra?  muscle. 

We  next  come  to  the  meml)ranous  or  fixed  portion  of  the 
canal,  which  is  surrounded  by  the  compressor  urethrae  muscle 
and  limited  in  extent  by  the  anterior  and  posterior  layers 
of  the  triangular  ligament. 

The  prostatic  portion,  situated  as  it  is  in  the  prostate 
gland,  and  extending  from  its  apex  to  its  base,  presents  the 
following  structures  upon  its  floor:  Running  longitudinally  in 
the  median  line  is  the  verumontanum  or  caput  gallinaginis, 


STRICTURE  OF  THE   URETHRA  117 

coiitiiiiiiiiK  on  its  smiiiiiit  (lie  Drilicc  of  tlic  uterus  riiusciilimis, 
on  cacli  side  of  which  is  the  opening  of  the  common  ejaciilatory 
duct.  '^I'hc  i)rostatic  ducts  open  into  the  prostatic  sinuses, 
which  arc  situated  on  each  side  of  the  vcruniontatunn.  It 
will  therefore  l)e  seen  tluit  the  seniiual  vesicles,  testicles,  and 
prostate  gland  are  in  direct  communication  with  \\\\<  portion 
of  the  urethra  by  means  of  their  ducts. 

The  total  length  of  the  urethra  varies  in  different  indi- 
viduals and  under  different  conditions,  the  average  being 
from  about  seven  to  eight  and  one-half  inches  (17.5  to  21.5 
cm.);  this  is  somewhat  increased  in  hyi)ertroi)hy  of  the 
prostate  gland. 

The  penile  and  bulbous  portions  together  measure  a})out 
six  and  one-half  (65)  inches  (16.5  cm.);  the  membranous 
about  three-quarters  (f)  of  an  inch  (2  cm.);  and  the  pros- 
tatic portion  one  and  one-quarter  (Ij)  inches  (3.25  cm.). 

Being  a  collapsed  canal,  and  in  no  sense  of  the  term  a 
tube,  the  urethra  has,  strictly'  speaking,  no  caliber,  l)ut 
merely  a  degree  of  dilatability  which  varies  greatly  in 
different  individuals  and  in  different  portions  of  the  same 
urethra,  there  being  certain  points  of  physiological  contrac- 
tion and  dilatation,  which  points  are  well  shown  in  Fig.  34, 
which  was  drawn  from  a  plaster  cast  of  the  normal  urethra. 

Therefore,  in  examining  a  patient  for  stricture  of  the 
urethra,  the  surgeon  must  bear  in  mind  the  fact  that  the 
meatus  urinarius,  the  middle  of  the  pendulous  portion,  and 
the  membranous  portion  are  normally  narrower  than  the 
rest  of  the  urethra,  and  also  that  the  fossa  navicularis,  the 
bulb,  and  the  middle  of  the  prostatic  portion  are  larger  and 
more  dilatable;  and  that  if  the  urethra  is  overdistended 
with  examining  instruments,  these  physiological  contrac- 
tions are  verv  liable  to  be  mistaken  for  strictured  areas. 


118 


STRICTURE  OF  THE   URETHRA 


Tlir  sliajK'  of  the  iirothra  varies  greatly  in  the  ditlVrcnt 
regions  of  the  canal,  being  vertical  at  the  meatus  and  through- 
out the  fossa  na\icularis,  transverse  in  the  penile  or  i)en(lu- 
Idus  urethra,  and  like  an  inverted  Y  in  the  middle  of  the 
prostatic  portion,  thus  A;  this  formation  is  due  to  the 
jutting  uj)  of  the  \eruni()ntanum  from  the  floor  of  the  pros- 
tatic urethra. 


Fig.  34. — Showing  points  of  contraction  and  dilatation  in  a  normal  urethra. 

(Thompson.) 

1.  Meatus  urinarius 21  to  28  French. 

2.  Fossa  na%'icularis 30  to  33 

3.  Middle  of  pendulous  portion  .      .  27  to  30 

4.  Bulbous  portion 33  to  36 

5.  Membranous  portion 27 

0.  Apex  of  prostatic  portion        ....  30 

7.  Middle  of  prostatic  portion    ....  45 

8.  Base  of  prostatic  portion 33 

9.  Indentation  caused  by  verumontauum. 


Etiology  of  Stricture. — The  \Rst  majority  of  cases  of  urethral 
stricture  are  due  to  gonorrheal  urethritis. 

Traumatism  is  the  etiological  factor  in  a  small  percentage 
of  cases. 

Congenital  stricture  is  occasionally,  though  cjuite  rarely, 
encountered. 

Traumatic  stricture  is  usually  single,  and  may  occur  in 
any  portion  of  the  urethra,  depending  on  the  seat  of  injury. 
In  the  pendulous  urethra  it  usually  follows  injury  of  this 
portion  of  the  penis  from  various  causes.       In  the  vast 


HTlUCTUItK  OF   Tflf'J    UliKTIIUA 


H) 


majority  of  cases  it  is  roniid  in  the  hiilhoiis  or  iiiciiiKniiiDu,-, 
portions  or  at  the  hulhonicinhranons  jnnctioii;  in  tlic^c 
regions  it  follows  falls,  kicks  or  blows  upon  tli('  perineum, 
causing  i)artial  or  complete  rupture  of  the  un^tlira,  either 
with  or  without  fracture  of  the  pelvis.  It  may  also  result 
from  caustic  injections  into  the  urethra,  in  which  case  the 
region  of  the  fossa  navicularis  is  the  most  usual  site  of  the 
constriction. 

At  the  time  of  the  injury  these  patients  have  more  or  less 
difficulty  in  urination,  or  even  complete  retention  of  urine, 
with  extravasation  of  blood  and  urine  into  the  surrounding 


'>X%  ins.  i      2'  o  to  3  ins.       I    2;^  ins. 
Fig.  35. — Showing  division  of  urethra  into  regions.     (Thompson.) 


tissues.  Bleeding  from  the  meatus  may  be  either  scanty  or 
free,  depending  upon  the  severity  and  extent  of  the  uretlu-al 
traumatism. 

For  a  description  of  urinary  extravasation  and  its  treat- 
ment the  reader  is  referred  to  page  132. 

Congenital  stricture  is  occasionally  observed.  It  may 
occur  in  any  portion  of  the  uretlira,  but  especially  at  the 
meatus,  or  just  beyond  it  in  the  fossa  navicularis. 

For  conciseness  and  clearness  of  description  in  regard  to 
the  location  or  seat  of  gonorrheal  stricture  we  will  follow  the 
plan  of  Sir  Henry  Thompson,  who  di\-ides  the  urethra  into 
three  regions  as  follows  (Fig.  35) : 


120  STRICTURE  OF   THE   URETHRA 

Region  I  iiu-huk's  all  nf  tlu'  nu'iuhraiious,  and  one  inch  of 
the  bulbous  uretlira,  and  is  thcrctnrc  al)()ut  one  and  three- 
quarters  (If)  mclies  iu  length. 

Recjion  II  extends  from  tin-  anterior  hinit  of  Kej^ion  I,  to 
within  two  and  a  half  (2|)  inches  of  the  meatus,  its  length 
varying  from  two  and  a  half  to  three  (2|  to  3)  inches. 

Rc(/i(»i  III  includes  the  first  two  and  a  half  (2-2)  inches 
of  the  canal  from  the  meatus. 

Thompson  found  that  the  vast  majority-  of  gonorrheal 
strictures  were  located  in  the  bulbous  urethra,  and  at  the 
bulbomembranous  junction,  or  Region  I;  next  in  the  region 
of  the  fossa  navicularis,  or  Region  III;  and  least  frequent! \- 
in  the  middle  of  the  jjendulous  urethra,  or  Region  IT. 

Primary  gonorrheal  stricture  of  the  prostatic  urethra  has 
never  been  found,  the  changes  in  this  portion  of  the  canal 
being  due  to  submucous  cell-infiltration,  which  does  not  go 
on  to  true  stricture-formation. 

The  reason  for  the  so  frequent  occurrence  of  gonorrheal 
stricture  in  the  bulb  of  the  urethra  and  fossa  na\icularis  is 
the  fact  that  in  these  regions  the  mucous  membrane  is  lax 
and  surrounded  by  a  large  amount  of  erectile  and  vascular 
tissue,  an  arrangement  that  tends  to  prolong  a  gonorrheal 
inflammation  which  has  settled  there,  which  naturally 
results  in  more  or  less  cicatricial  contraction. 

In  the  majority  of  cases  gonorrheal  stricture  is  single, 
although  sometimes  there  may  be  two,  three,  or  even  foiu' 
well-marked  contractions  in  the  same  case. 

This,  however,  is  not  at  all  common,  and  when  found  is  in 
all  probability  due  to  a  continuation  of  the  same  pathological 
process,  either  from  the  l)ulb  forward,  or  vice  versa,  and  con- 
stitutes what  is  known  as  a  tortuous  stricture,  which  may 
invt)lve  the  canal  for  an  inch  or  so;  or  even  for  its  entire 


ST  III  CT I J  UK  OF   TIIK    URETHRA  121 

l('iij;'tJ),  t.lius  coiixcrf  iii<j,'  it  into  ;i  lliickciicd  liihc  witli  irrc^Mi- 
larly  contracted  liiiiicn. 

(TOiiori'Jical  stricture,  us  m  rule,  conies  on  slowly,  and  in 
the  majority  of  casi^s  does  not  give  ris(!  to  marked  or  urgent 
symptoms  until  several  years  after  liie  initial  attack  of 
gonorrhea.  This  is  shown  by  the  fact  that  the  great  majority 
of  men  apply  for  treatment  between  tlieir  twenty-fiftii  ;ind 
fortieth  years. 

There  are  some  exceptional  cases,  however,  in  which  symp- 
toms are  observed  as  early  as  the  first  year  after  the  acute 
urethral  inflammation;  which  goes  to  show  that  stricture- 
formation  is  in  some  cases  very  rapid  mdeed,  and  tJiat  the 
physician  should  always  accurately  ascertain  the  condition 
of  the  urethral  mucous  membrane  before  beginning  any 
form  of  local  treatment. 

Pathology  of  Stricture. — As  a  result  of  the  gonorrheal 
process  there  is  a  small,  round-cell  infiltration  into  the  sub- 
mucous connective-tissue  layer,  which  constitutes  the 
essential  lesion  of  stricture.  This  infiltration  is  soft  and 
yielding  at  first,  and  if  sufficient  in  amount  to  cause  any 
loss  of  urethral  caliber  is  called  "soft"  stricture. 

As  the  process  ad^•ances,  however,  the  small  round  cells 
are  replaced  by  connective-tissue  cells,  and  we  then  have 
a  fully  formed  ''semifibrous"  structure,  which  in  time  becomes 
innodular  and  densely  fibrous  and  causes  more  or  less  impair- 
ment of  the  urethral  lumen,  with  loss  of  dilatability  (Figs. 
36,  37,  and  38). 

These  cell-changes  may  be  sharply  limited  to  the  sub- 
mucous connective-tissue  layer  or  involve  the  corpus 
spongiosum  to  a  greater  or  less  degree,  giving  rise  to  a 
periurethritis. 

The  mucous  membrane  over  the  stricture  becomes  more  or 


122 


STRICTURE  OF  THE   URETHRA 


less  tliic'keiu'd  and  loses  its  smootli  and  sliining  appearance, 
owing  to  a  chronic  catarrlial  inflannnation. 

From  the  above  it  will    be  clearly  seen  that  all  gone)r- 
rheal  strictures  are  soft  and  yielding  at  first,  and  can  there- 


stricture. 


Fig.  3G. — Stricture  of  the  bulbous  portion  of  uretlira.     (College  of 
Physicians  and  Surgeons.) 


STRICTURK  OF   TIN':   VimTIIHA 


123 


Stricture. 


Stricture. 


Fig.  37. — Strictures  of  urethra;   one  at  the  bulbomembranous  junction  and 
one  in  the  pendulous  portion.     (College  of  Phj-sicians  and  Surgeons.) 


124 


STRICTURE  OF  THE    URETHRA 


Stricture. 


Fig.  38. — Stricture  of  the  V)uUjomenibranous  junction.  Note  hypertrophy 
of  the  bladder  walls  and  contraction  of  the  bladder.  (College  of  Physicians 
and  Surgeons.) 


SriilCTlIRE   OF   Till':    IIIiKTIIliA 


125 


fore  l)c  rcjidily  cured  l)y  ^riidiuil  (lil;itiiti(»ii  iiiid  locid  iirctlind 
medication  during  tliat  stage.  WJien  they  have  become 
densely  fil)r()us  and  Jiard,  however,  we  are  obHged  to  resort 
to  some  of  the  various  operative  measures  described  in 
Chapter  XIV. 


Tortuous  or  irregular. 
Fig.  39. — Urethral  strictures. 


Forms  of  Stricture. — A  Hnear  stricture  consists  of  one  or 
more  thread-like  bands  situated  just  beneath  the  mucous 
membrane  and  encircling  the  urethra  to  a  greater  or  less 
degree. 

An  annular  stricture  consists  of  a  broader  ring  of  stenosis 
than  the  linear  variety.  If  the  narrowing  involves  an  inch 
or  more  of  the  canal,  we  then  speak  of  it  as  an  irregular  or 
tortuous  stricture  (Fig.  39). 

The  position  of  the  opening  in  any  of  these  forms  of 
stricture  may  be  eitlier  central  or  excentric. 


12G  STRICTURE  OF   THE    URETHRA 

The  so-called  spasmodic  stricture  is  due  to  tlie  contrac- 
tion of  the  compressor  urctlnw  muscle,  or  to  the  circular 
muscular  fibers  of  the  uretlu'a,  and  being  merely  a  temporary- 
condition  of  muscular  spasm,  must  not  be  looked  upon  as 
a  true  stricture,  Mhich  is  ahvays  due  to  pathological  changes 
in  the  canal. 

It  occurs  most  frequently  in  nervous  subjects.  The 
spasm  may  be  caused  by  the  rapid  or  unskilful  passage  of 
urethral  instruments,  operations  on,  or  diseases  of,  the 
external  genitals,  rectum  and  anus,  highly  acid  urine,  the 
long  retention  of  urine;  or,  in  some  cases,  from  a  feeling  of 
shame  or  fear,  as  when  patients  are  unable  to  pass  their 
urine  before  a  class  or  even  in  the  presence  of  the  examining 
surgeon.  It  may  also  result  from  fault}-  urethral  treatment, 
especially  the  Janet  method,  and  sometimes  complicates 
affections  of  the  bulb  and  deep  urethra,  and  also  of  the 
prostate  gland  and  adjacent  structures. 

The  condition  is  also  found  as  a  complication  of  typhoid 
fexcr,  transverse  myelitis,  tabes  and  other  affections  of  the 
spinal  cord,  and  after  operations  in  the  abdominal  cavity 
and  for  inguinal  hernia. 


CHAPTER  XI. 
SYMPTOMS  OF  STRICTURE. 

The  symptoms  of  stricture  vary  greatly  in  different  cases, 
their  severity  depending  both  upon  the  degree  of  contraction 
and  also  the  extent  of  the  strictured  area. 

As  a  general  rule,  there  is  more  or  less  serous  or  sero- 
purulent  discharge  from  the  meatus,  which  may  even 
amount  to  a  drop  or  so  in  the  morning,  or  only  to  a  gluing 
together  of  the  meatus;  in  other  cases,  however,  there  is  no 
discharge. 

If  the  morning  urine  is  examined,  it  will  be  found  to 
contain  shreds  and  flakes  floating  about  in  a  clear  or  turbid 
urine. 

The  meatus  is  often  quite  blue  in  color  from  congestion 
caused  by  the  cicatricial  tissue  around  the  urethral  walls, 
which  interferes  more  or  less  with  the  return  circulation. 

As  the  stricture  contracts  there  is  more  or  less  dilatation 
of  the  urethra  behind  it,  caused  by  the  damming  back  of  the 
stream  at  each  act  of  urination;  this  mechanical  irritation 
in  time  causes  congestion  and  inflammation  of  the  urethral 
mucous  membrane  from  the  posterior  surface  of  the  stricture 
up  to  and,  in  some  cases,  into  the  bladder,  so  that  these 
patients  really  have  posterior  urethritis,  with  more  or  less 
prostatitis  and  urethrocystitis,  which  gives  rise  to  an  increased 
frequency  in  urination,  which  may  be  preceded,  accompanied, 


12S  SYMPTOMS  or  STRICTURE 

or  followed  by  a  varying  amount  of  ])ain  and  uneasiness  in 
the  urethra,  i)erineum,  prostate,  and  testes. 

As  the  stricture  contracts,  the  muscular  walls  of  the 
bladder  u\:\y  hypertrophy  from  the  extra  anioiiiit  of  pressure 
they  arc  comjx'llcd  to  exert  in  order  to  empty  that  viscus 
through  the  stenosed  canal.  The  urine  now  comes  with  less 
force,  and  caimot  be  thrown  any  distance  from  the  meatus; 
in  severe  and  neglected  cases  it  comes  in  scalding,  blood- 
stained drops,  which  can  only  be  expelled  by  severe  and 
long-continued  straining;  which  in  time  may  cause  either 
hernia,  hemorrhoids,  or  prolapse  of  the  rectum,  aufl  be 
associated  with  evacuation  of  the  bowel  at  each  attenii)t  at 
urination. 

As  a  result  of  the  inflammation  in  the  prostatic  urethra 
and  sometimes  in  the  gland  itself,  these  patients  may  have 
either  painful  erections  or  nocturnal  pollutions,  or,  if  the 
inflammatory  process  involves  the  ejaculatory  ducts,  epididy- 
mitis, epididymo-orchitis,  or  seminal  vesiculitis. 

Some  cases  at  this  time  have  a  constant  dribbling  of  urine 
from  the  meatus,  this  incontinence  being  due  to  a  loss  of 
contractile  power  of  the  vesical  sphincters. 

Retention  of  urine  may  occur  at  any  time  during  the  course 
of  stricture-formation;  in  some  cases  it  is  the  first  symptom 
that  calls  the  patient's  attention  to  his  real  condition;  it  is 
due  to  a  sudden  swelling  of  the  mucous  membrane  coNcring 
the  stricture,  caused  by  irritating  urine,  OA-erzealous  instru- 
mentation, catching  cold,  sexual  or  alcoholic  excesses,  etc., 
some  patients  being  more  prone  to  this  complication  than 
others. 

If  cystitis  is  well  marked,  patients  complain  of  constant 
and  deep-seated  pain  o\er  the  bladder. 
'  The  urine  in  some  of  these  advanced  and  neglected  cases 


SYMPTOM!^  OF  STIilCTUIlK  IL'!) 

becomes  ;iiiinioiii;ic;il  in  reaction,  bloody,  and  lu.idcd  willi 
crystii.ls  iiiid  ])us,  wJiicIi  latter,  })eing  coagiiliitcd  in  llic 
bladder  by  the  ammojiia,  causes  a  ropy  and  gelatinous  c<jn- 
dition  of  the  urine,  which  is  liable  to  obstruct  the  eye  of 
the  instrument  during  catheterization.  If  the  above  con- 
dition of  the  urine  is  not  modified  by  j)roprr  treatment  it 
may  result  in  stone-formation. 


CHAPTER  XIT. 

COIMPLICATIONS  OF  STRICTURE. 

That  portion  of  tlie  urethra  situated  behintl  the  stricture, 
as  ah'eady  stated,  becomes  dilated  to  a  greater  or  less  extent, 
and  its  mucous  membrane  and  connective-tissue  layer  become 


Fig.  40. — Urethroscrotal  fistulie  complicating  tight  stricture  of  the 
bulbous  urethra.     (Author's  case.) 


much  thickened;  the  orifices  of  the  i)rostatic  sinuses  and  the 
ejaculatory  ducts  which  are  situated  in  the  floor  of  the 
prostatic   urethra  are  also   dilated;  these  changes  are   all 


DIVERTICULA    OF  liLADDFJi.  I'il 

produced  by  tlic  back  pressure  of  the  urine,  whose  hvr  out- 
ward passage  is  prevented  by  tlie  stenoscd  iuifl  ihirkcncd 
canal. 

ABSCESSES    AND    FISTULA. 

Abscesses  and  iistulie  niu.>'  fonn  bcliiiid  tiie  stricture,  (origi- 
nating in  inflamed  urethral  follicles  or  ulcerated  spots  into 
which  the  urine  escapes,  and  finally  burrows  in  fistulous 
tracts,  which  may  open  in  the  perineum,  on  the  buttocks, 
the  scrotum,  or  the  abdomen  (Fig.  40). 

In  some  severe  cases  abscesses  of  Cowper's  glands  or  of 
the  prostate  occur,  which,  if  untreated,  may  rupture  either 
into  the  urethra,  bladder,  peritoneal  cavity,  perineum,  or 
rectum. 


Fig.  41. — Cystoscopic  photograph  of  diverticulum  of  bladder. 
(Author's  case.) 


DIVERTICULA    OF   BLADDER. 

The  bladder  walls  become  greatly  thickened  from  hyper- 
trophy of  the  muscular  layer,  which  causes  trabeculie  of 
muscular  tissue  to  project  into  the  viscus;  between  these 
ridges  the  bladder  wall  may  become  very  thin  and  dilated, 
going  on  to  the  formation  of  sacculi  and  diverticula  (Fig.  41), 
which  may  in  time  rupture  and  allow"  the  contents  of  the 


132  COMPLICATIONS  OF  STRICTURE 

l)l:i(l(ler  to  cscaj)c'  iiit(»  tUv  peritoneal  Ciivity.  Vesical  calculi 
may  also  be  foiiiul  lying  in  these  diverticula  or  embedded 
in  the  recesses  between  the  trabecule. 

URETERS. 

Follo\\  ing  these  (haunt's  in  tlie  bladder,  the  ureters  become 
dilated,  as  do  tlie  ])('l\(>s  of  the  kidneys,  the  secreting  por- 
tions being  pushed  out  and  compressed  by  the  accunndated 
urine.  The  inflammation  ascending  from  the  bladder  through 
the  ureters  finally  enters  the  pelves  of  the  kidneys,  causing 
pyelitis  or  pyelonephritis  on  one  or  both  sides,  Avith  all  of 
their  concomitant  symptoms. 

EXTRAVASATION    OF   URINE. 

The  urethra  behind  the  stricture  having  become  thin 
and  weakened  may,  as  the  result  of  violent  straining,  or 
without  any  apparent  cause,  give  way  and  allow  the  urine 
to  escape  into  the  surrounding  tissues  in  greater  or  less 
amount.  Extravasation  of  urine  also  occurs  in  partial  or 
complete  rupture  of  the  urethra  from  falls,  blows  and  kicks 
on  the  perineum,  either  with  or  without  fracture  of  the  pelvis. 
The  urethra  may  gi\e  way  or  be  ruptured  in  any  of  the  fol- 
lowing regions,  depending,  of  course,  upon  the  site  of  the 
stricture  or  the  point  of  injury: 

1.  Between  the  meatus  and  the  penoscrotal  junction. 

2.  Between  the  penoscrotal  junction  and  the  anterior 
layer  of  the  triangular  ligament. 

3.  In  the  membranous  urethra;  that  is,  between  the 
anterior  and  posterior  layers  of  the  triangular  ligament. 

4.  Behind  the  posterior  layer  of  the  triangular  ligament. 


EXTRAVASATION  OF   URINE  1.''.3 

It  is,  of  course,  possible  iind  not  iiiicoiniiioii  for  two  of  i\\c^c 
regions  to  be  iiicliidcd  l)\'  tlic  nij)tiirc  of  the  iirctlirjil  wall  at 
the  same  tiiiic. 

The  constitutional  symptoms  of  extravasation  are  as  fol- 
lows: The  patient  sometimes  experiences  a  sudden  sensation, 
as  if  something  had  given  way  in  some  part  of  the  urethra; 
this  is  followed  by  a  feeling  of  momentary  relief,  speedily 
accompanied  by  swelling  of  the  penis,  hypogastrium,  scrotum, 
or  perineum,  according  to  the  locality  of  the  rupture.  The 
patient  at  this  time  has  fever,  with  chilly  sensations  or  well- 
marked  chills  and  a  feeling  of  general  malaise,  and  if  not 
radically  and  speedily  treated  by  operation,  passes  into  a 
condition  of  extreme  shock,  and  finally  dies  of  a  general 
septicemia. 

The  skin  over  the  swelling,  which  at  first  is  very  tense, 
bright  red  in  color,  and  shining  in  appearance,  soon  becomes 
gangrenous,  sloughing,  and  em.physematous  from  the  pres- 
ence of  the  gases  situated  beneath  it,  which  are  produced  by 
the  purulent,  decomposing,  and  sometimes  ammoniacal  urine 
extravasated  through  the  tissues  (Figs.  42,  43,  44,  and  45). 

It  is  an  established  fact  that  normal  (sterile)  urine  does  not 
cause  gangrene  or  destruction  of  the  tissues  even  when 
injected  beneath  the  integument  in  considerable  quantities. 

The  situation  of  the  swelling  varies  according  to  the  point 
of  rupture  and  the  time  that  has  elapsed  since  the  injury  or 
accident. 

When  the  opening  in  the  urethra  occurs  between  the 
meatus  and  the  penoscrotal  junction  the  extravasation  takes 
place  into  the  tissues  of  the  corpus  spongiosum,  pushing  for- 
ward into  the  glans  penis  and  causing  great  swelling  of  that 
organ. 

When  the  rupture  occurs  between  the  penoscrotal  junction 


134  COMPLICATIONS  OF  STRICTURE 


Fui.  42. — Extnivasatiou   of  urine  into  penis,  scrotum,  and  y\<^\ii  buttocl 
(Author's  case.) 


Fig.  43.— E.\trava.sation  of  urine  iulu  scrotum.      (Author's  case.) 


EXTRAVASATION  OF   IJIiINK 


]  ?,: 


Fig.  44. — Extravasation  of  urine  into  scrotum  and  over  symphysis. 
(Author's  case.) 


Fig.  45. — Extravasation  of  urine,  with  gangrene  and  sloughing  of  scrotum. 
(Author's  case.) 


130  COMPLICATIONS  OF  STRICTURE 

and  the  anterior  layer  of  the  trian<iular  li.uiiinent  the  urine 
is  extra\iisiite(l  into  the  scrotal  tissues  and  upward  on  tlie 
h\i)ogastriuni,  sometimes  as  far  as  the  umi)iHeus. 

When  the  rupture  takes  plaee  between  the  anterior  and 
jjosterior  layers  of  the  trianguhir  ligament  (in  the  mem- 
branous urethra)  the  urine  is  at  first  confined  between  these 
layers,  but  soon  makes  its  way  baekwarfl  into  the  ])el\ie 
cavity,  or,  in  exceptional  cases,  burrows  forward  into  the 
perineum. 

When  rupture  takes  place  beliind  the  posterior  layer  of  the 
triangular  ligament  the  urine  passes  either  into  the  recto- 
vesical space,  and  thus  works  down  to  the  perineum,  or 
passes  upward  into  the  pelvic  tissues  and  in  front  of  the 
bladder. 

Treatment. — No  matter  how  great  or  small  the  amount  of 
extraAasated  urine  is,  we  must  always  bear  in  mind  the  fact 
that  there  is  a  constant  leakage  of  septic  urine  through  a 
more  or  less  damaged  urethra;  and  that  in  order  to  check  it 
the  bladder  must  be  promptly  drained  through  the  perineum, 
and  the  stricture  cut.  This  must  be  done  without  delay,  as 
the  longer  it  is  put  off,  the  greater  the  extravasation  becomes, 
and  this,  if  left  uncontrolled,  means  abscess-formation,  or 
sloughing  and  gangrene  of  the  soft  parts,  and  finally  death 
from  absorption  of  septic  material. 

The  patient,  ha^'ing  been  anesthetized,  is  })ut  in  the  lithot- 
omy position,  and  the  parts  shaved  and  rendered  surgically 
clean  in  the  usual  manner. 

External  urethrotomy,  or  external  and  internal  urethrotomy 
combined,  or  perineal  section,  is  then  performed,  according  to 
the  manner  described  under  perineal  operations  for  bladder 
drainage  and  stricture  of  the  urethra,  to  which  the  reader 
is  referred  (p.  165).    All  of  the  stricture  tissue  having  been 


EXTRAVASATION  OF   URINE  ]'A7 

thoroughly  (livi<l('(l  jukI  ii,  I'lill-sizcd  sound  |)iiss(;(],  a  \:)visf 
perineal  tube  is  inscrlcd  into  the  Miuldcr  ;ind  -iccnrfd  in  1 1n- 
usual  maimer. 

By  free  and  dee])  incisions  all  of  tlic  cxtravasated  urine 
nmst  be  liberated,  the  sloughy  and  gangrenous  tissues 
rcMuoved,  and  bleeding-])oints  controlled.  The  incisions  are 
tJioroughly  irrigated  with  peroxide  of  hydrogen,  followed  })y 
hot  saline  solution,  and  lightly  packed  with  moist,  sterile 
gauze. 

The  incisions  are  kept  scrupulously  clean  by  frequent 
irrigation  and  dressing,  and  treated  on  general  surgical 
principles. 

If  urinary  abscesses  or  fistulae  exist,  they  must  be  freely 
opened  and  scraped,  or  resected  and  drained  at  the  time  of 
the  perineal  operation,  if  the  patient's  condition  warrants  it, 
otherwise  they  may  be  left,  and  attended  to  at  a  later  date. 

For  the  condition  of  shock,  which  usually  complicates  these 
cases,  we  should  employ  subcutaneous,  intravenous,  or  rectal 
injections  of  normal  saline  solution,  both  before,  during,  and 
if  necessary,  after  the  operation. 


CHAPTER  XIII. 
DIAGNOSIS  OF  STRICTURE. 

In  order  to  ascertain  the  presence  of  stricture,  its  situa- 
tion, consistency,  and  caliber,  the  following  instruments 
are  necessary : 

Filiform  and  olivary  pointed  bougies,  bougies  a  boule,  or 
acorn-pointed  bougies,  steel  sounds,  a  scale  plate  and  measure 
combined,  and  for  certain  selected  cases,  a  urethrometer. 

The  scale  plate,  as  well  as  all  of  the  urethral  instruments, 
should  be  made  and  marked  according  to  the  French  scale, 
which  runs  as  follows: 

No.  1  French  =  I  of  a  millimeter  in  diameter. 
No.  2  French  =  |  of  a  millimeter  in  diameter. 
No.  3  French  =  1  millimeter  in  diameter. 

Thus  it  will  be  seen  that  each  instrument  increases  in  size 
by  one-third  of  a  millimeter  in  its  diameter. 

The  American  and  English  scales,  which  are  far  inferior 
to  the  French,  are  \ery  irregular  and  little  used  at  the  present 
time  and  therefore  Avill  not  be  described. 

Scale  plate:  The  scale  plate  or  gauge  (Fig.  46)  is  made  of 
nickel-plated  steel,  with  numbers  or  sizes  running  from 
No.  1  to  No.  35  French,  inclusi^•e,  although  it  is  rarely  neces- 
sary to  use  an  instrument  larger  than  a  No.  30  or  32  F. 
One  edge  is  marked  in  inches,  like  a  rule,  so  that  it  can  be 
used  for  measuring  the  distance  from  the  meatus  at  which 
instruments  are  stopped  by  the  stricture. 


DfAO'NOSIS  OF  HT  HI  era  UK 


130 


FRENCH        SCALE. 

,    2   3  4    5      6       7      8       9        10       II        12       13        14        15  16         17  18  19         20  21  22 

ooooo  o  OOOOOOOOOOOOOOOO 


3b        34        33       -id  31      30     29     28     27     26    25    Z'k  23 


I 


G.TIEMANN  StCO 

2  1  31  4  1  5  1  fi 

il  rl  I  lili  h  Irhlil  I  n  lilil  rl  ll  III  I  il  ih  nhlJ  il  il  I  I  il  ml  I  li  I  ilil  Hi 


Fk;.  4('). — Scule  i^lali^  iiiid  mcasun 


Fig.  47. — Author's  sound. 


Fig.  4S. — Olivarj'  bougie. 


140 


DIAGNOSIS  OF  STRICTURE 


Sounds:     Souiuls  are  made  of  smooth,   highly   polished 
nickel-plated  steel,  and  siiould  run  from  No.  18  to  Xo.  32  or 


.;  TIEMANN  i  CO. 


.;.T,c:.i,-.UNilCO. 


C.TICMANN  .-XCO. 


G. TIEMANN  tt  CU. 


Fig.  49. — Whalebone  filiform  bougies. 


even  Xo.  35  French,  inclusive.  Thej^  should  ]ia\e  a  gentle 
and  eas\-  cur\e  and  a  conical  point,  which  is  three  sizes  smaller 
than  the  shaft  (Fig.  47). 


3£ 


Fig.  50.— Silk  bougie  ii  boule. 


Olivary  Bougies:  The  French  olivary  bougies  are  the  best. 
They  are  black  or  yellow  in  color,  with  a  very  smooth  and 
highly  polished  finish.     (See  Fig.  48.) 


Fig.  51. — Otis  urethrometer. 


The  shaft  tapers  gradually  into  the  neck,  which  terminates 
in  the  olivary  end,  this  being  about  seven  sizes  smaller  than 


J)JA(,'N()S/S  OF  STUIf'TlIUK  141 

tlie  shaft.  Tlicsc  l)()ii<:;ics  must  Ix'  (Icxihlc;,  so  as  to  ;Hl;i|)t 
themselves  to  the  curves  of  tlu;  ur(!thi-;i,  ;iinl  should  i-iin 
from  No.  3  to  No.  18  or  No.  20  FrencJi,  inchisivc. 

Filiform  Bougies:  Whalebone  filiform  boyj^ies  are  the  best 
(Fig.  49).  They  are  twelve  inches  in  lengtli  and  arc  about 
No.  1  to  3  of  the  French  scale  in  size;  the  shaft  must  })e 
smooth  and  highly  polished,  and  terminate  in  a  tin}'  bulb. 
The  points  of  some  of  the  instruments  may  be  turned  and 
twisted  in  various  ways,  in  order  to  facilitate  their  entrance 
into  irregular  strictures.  The  remainder,  however,  should 
be  made  straight,  and  in  my  hands  are  really  the  most  useful 
for  cases  of  tight  stricture.  The  surgeon  should  have  a 
dozen  at  least. 

Bougies  a  boule:  These  instruments  should  be  soft  and 
flexible,  as  is  well  shown  in  Fig.  50.  Those  made  of  metal 
cause  more  pain,  and  do  not  give  the  examiner  as  good  an 
idea  of  the  condition  of  the  urethral  walls,  and  should  not, 
therefore,  be  employed.  The  shoulder  of  the  bulb  should  be 
well  marked  and  smooth.  It  is  best  to  have  a  set  of  these 
bougies  from  No.  8  to  No.  32  French,  inclusive. 

The  Urethromeier:  The  Otis  urethrometer,  if  employed  intel- 
ligently and  conservatively,  is  a  useful  instrument  for  detect- 
ing and  locating  strictures  in  a  patient  with  an  abnormally 
small  meatus  (16  to  18  French).  If,  however,  the  little 
bulb  is  screwed  up  too  high  and  then  withdrawn,  there  is 
great  danger  of  mistaking  the  physiological  contractions  and 
circular  muscular  fibers  of  the  methra  for  true  strictures. 

The  instrument  (Fig.  51)  consists  of  a  No.  8  French 
straight  cannula,  terminating  in  a  bulb  made  up  of  short 
arms,  which  can  be  dilated  (1)  and  contracted  (2)  by  means 
of  a  rod  running  through  the  cannula  and  terminating  in  a 
screw  at  the  handle  of  the  instrument.    A  thin  rubber  shield 


142  DIAGNOSIS  OF  STRICTURE 

(3)  is  (Iniwn  ()\rr  the  nu'tallic  hull)  to  ])r()t('ct  the  urrthra 
from  injury.  Tlic  index  on  the  liandle  shows  tlie  size  in 
inillinieters  to  which  the  bulb  has  been  dihited  or  contracted. 
The  bulb  when  closed  is  about  No.  IG  to  No.  18  French, 
but  can  (altliougli  it  never  should)  be  expanded  up  to  No.  40 
or  45  of  that  scale  by  turning  the  screw  at  the  handle,  which 
indicates  at  the  same  time  the  increase  in  size  on  the  index. 

Being  a  straight  instrument,  it  can  only  be  employed  for 
examining  the  anterior  uretlira. 

Before  exploring  the  urethra  with  instruments  we  should 
always  ascertain  the  date  of  the  gonorrheal  infection  as  well 
as  its  duration,  severity,  and  complications,  as  these  points 
will  throw  much  light  on  the  patient's  present  condition. 
If  there  is  a  mucopurulent  or  purulent  urethral  discharge, 
witli  swelling  and  redness  of  the  meatus,  the  patient  must 
be  put  on  appropriate  treatment,  and  instrumentation 
fief  erred,  unless  imperative,  until  all  of  the  acute  inflamma- 
tory symptoms  have  subsided.  Inquire  into  the  frequency 
of  urination  during  the  day  or  night;  if  it  is  painful  or 
causes  uneasiness  in  the  region  of  the  prostate;  also,  if  there 
is  any  morning  discharge  or  sticking  of  the  lips  of  the  meatus. 
Ascertain  if  ejaculation  is  premature  or  painful,  or  if  noc- 
turnal pollutions  are  too  frequent  or  painful,  or  the  ejaculate 
bloody.  Ask  if  there  is  a  dribbling  of  urine  after  urination, 
or  any  change  in  the  character,  force,  or  size  of  the  stream. 
If  anything  in  the  patient's  history  points  to  disease  in  the 
prostate  or  seminal  \'esicles,  these  structures  must  be  pal- 
pated by  a  finger  in  the  rectum,  and  their  expressed  secre- 
tions collected  at  the  meatus,  or  taken  from  the  urine  and 
examined  microscopically.  Have  the  patient  pass  his  urine 
in  a  glass  cylinder  at  the  time  of  his  visit;  this  is  carefully 
examined  for   gonorrheal  shreds,  pus,  nnicus,  albumin  and 


DIAGNOSIS  OF  STRICTURE  143 

casts,  ;is  these  elements,  l)y  tJieir  j)r(!sencc  in  tlic  niinc, 
together  with  a  history  of  the  case,  will  give  a  clear  ifJea  as 
to  the  extent  and  severity  of  the  urethral  and  even  bladder 
inflammation. 

The  following  rules  should  })e  carefully  carried  out  in 
making  all  urethral  examinations  or  explorations,  no  matter 
what  kind  of  instruments  are  to  he  employed:  I'he  patient 
should  be  put  upon  urotropin,  in  full  doses,  for  at  least 
twenty-four  hours  before  and  after  instrumentation,  and 
should  be  instructed  to  drink  large  amounts  of  water.  Rea- 
sonably large,  well-lubricated,  warm  and  sterile  instruments 
should  always  be  used  first,  as  small  and  cold  ones  are 
more  apt  to  irritate  the  urethra,  and  thus  cause  spasm,  which 
interferes  greatly  with  further  examination.  If  instrumen- 
tation causes  marked  bleeding  or  much  pain,  it  should  be 
stopped  immediately,  and  not  be  repeated  for  a  day  or  so, 
appropriate  treatment  being  employed  in  the  meantime. 

The  patient  having  urinated  in  order  to  wash  out  any  secre- 
tion that  may  have  collected  in  the  urethra,  lies  down  on  an 
operating  table,  with  head  and  shoulders  slightly  elevated  on 
a  pillow  or  cushion;  in  this  way  relaxing  the  abdominal  and 
perineal  muscles,  and  the  suspensory  ligament,  which  latter 
ru,ns  from  the  symphysis  pubis  to  the  dorsum  of  the  penis. 
The  clothing  should  be  drawn  down  as  far  as  the  knees  and 
up  to  the  mnbilicus,  as  by  so  doing  the  instrument  can  be 
readily  depressed  between  the  thighs  as  it  enters  the  bladder, 
and  at  the  same  time  we  can  note  the  median  line  by  the 
position  of  the  umbilicus  and  the  linea  alba.  The  glans 
penis  and  meatus  should  be  carefully  wiped  off  with  warm 
bichloride  solution,  and  the  prepuce,  well  retracted,  so  that 
the  penis  can  be  held  in  the  sulcus,  which  will  prevent  its 
slipping  from  the  examiner's  fingers. 


144  DIAGNOSIS  OF  STRICTURE 

Sterile  towels  aiT  now  placed  o\-er  the  j)atieiit's  thighs  and 
ahtloinen  to  i)revent  contact  with  the  sur^jeon's  liands  or 
instruinents.  A  sterile  tjperatint;'  sheet.  witJi  a  slit  in  the 
centre  for  the  penis,  is  even  better. 

For  examining  the  urethra  for  strietur(>,  the  best  instru- 
ment to  use  is  the  flexible  bougie  a  boule  (Fig.  50)  selecting 
one  that  will  readily  enter  the  meatus.  The  penis  is  held  at 
right  angles  to  the  body  by  means  of  the  thumb  and  index- 
finger  of  the  left  liand,  which  grasps  it  in  the  sulcus  behind 
the  corona.  As  the  bougie,  properly  cleansed  and  lul)ricated 
and  held  lightly  between  the  right  thumb  and  forefinger, 
sHdes  slowly  and  gently  down  the  canal  it  imparts  to  the 
examiner  an  accurate  idea  of  the  condition  of  the  uretlu-al 
walls:  whether  they  are  inelastic  and  rigid,  soft  and  pliable, 
or  the  seat  of  stricture,  in  which  last  case  it  will  slij)  througli 
the  contraction  with  a  jerk,  especially  as  it  is  being  drawn  out. 

A  steel  sound,  or  olivary  bougie,  is  not  suitable  for  this 
examination,  as  these  instruments  are  conical  and  liable  to 
dilate  a  soft  strictiu'e,  and  not  detect  it,  and  in  this  way  give 
the  examiner  a  faulty  idea  as  to  the  real  condition  of  the 
canal.  After  the  stricture  has  been  located  with  the  bougie 
a  boule  we  may  obtain  additional  information  with  regard  to 
its  size,  the  location  of  its  orifice,  wliether  central  or  eccen- 
tric, the  condition  of  the  mucous  membrane,  etc.,  by  exami- 
nation of  the  face  of  the  contraction  with  the  urethroscope. 
Great  care  must  be  taken  to  avoid  trauma,  how^ever,  and  it 
may  often  be  advisable  to  postpone  this  procedure  to  a  later 
occasion. 

Method  of  Passing  a  Sound. — An  instrument  is  selected  that 
enters  the  meatus  with  ease;  it  is  properly  cleansed  and 
lubricated,  and  passed  slowly  and  with  the  utmost  care  and 
gentleness  in  the  following  manner: 


DIAGNOSIS   OF  STiaCTIIUK 


145 


The  ()j)orut()r  stiuuls  on  the  left  side  of  I  lie  |);iti(iit,  lioMiiifr 
tlic  iKMiis  ill  the  coroiiiil  sulcus,  l)etw(!('ii  the  thiiinl)  ;iiiil  iiKJcx- 
fiiiger  of  the  left  liiuid;  in  this  wny  th(!  penis  is  put  on  the 
stretch  at  right  angles  to,  and  in  tJic  median  line  of,  tlic  body; 
thus  eflaeing  the  first  curve  of  the  nretJira.  'I'he  sonnrl  is 
held  lightly  between  the  thumb  and  first  two  fingers  of  the 
right  hand,  which  rests  on  the  median  line  of  the  abdominal 


Fig.  52. — Sound  entering  meatus.     (Original.) 


wall,  and  the  tip  of  the  instrument  is  gently  inserted  into  the 
meatus  (Fig.  52). 

The  hand,  still  resting  on  the  abdominal  wall,  urges  the 
sound  gently  into  the  urethra,  the  penis  at  the  same  time 
being  drawn  upward,  so  that  the  sm'geon's  hands  approach 
each  other  (Fig.  53).  At  this  time  the  tip  of  the  sound 
is  just  entering  the  bulb.  The  left  hand  now  drops  the 
10 


146 


DIAGNOSIS  OF  STRICTURE 


penis,  wliich  is  swept  slowly  dowiiwarfl  and  at  right  angles 
to  the  body  by  the  sonnd,  whose  tip  now  rests  against  the 
opening  in  the  triangular  ligament,  and  its  convexity  in  the 
bulb  of  tlie  urethra  (Fig.  5-4). 

In  order  to  reach  the  prostatic  portion,  the  handle  of  the 
instrument  is  gently  depressed,  it  being  now  held  in  the  left 
hand    (Fig.  55).      The   patient  usually  complains   at  this 


Fig.  53. — Tip  of  sound  entering  hulljous  urethra.      (Original.) 


time  of  a  desire  to  urinate,  owing  to  the  pressure  of  the 
instrument  on  the  mucous  membrane  of  the  prostatic 
urethra,  which  is  extremely  sensitive,  even  in  health. 

If  the  bladder  is  to  be  explored,  the  handle  of  the  sound  is 
depressed  still  farther  between  the  thighs  and  pushed  gently 
upward,  when  it  will  be  felt  to  glide  easily  into  the  bladder 
(Fig.  50). 


DIACNOSfS  OF  STRICTURE 


147 


Fig.  54. — Tip  of  sound  resting  against  anterior  surface  of  compressor 
urethra;  muscle  (membranous  urethra).      (Original.) 


Fig.  55. — Convexity  of  sound  resting  on  the  floor  of  the  prostatic  urethra. 

(Original.) 


148 


DIAGNOSIS  OF  STRICTURE 


Kn(loscoi)ic  tubes,  cyst().st'()])es,  iiivthrocystosc'ojK's,  stone- 
sea  rcliers,  lithotrites,  evacuating  tubes,  and  in  fact,  all 
instrinnents  used  in  the  tleep  urethra  and  bladder  are 
introduced  in  the  same  maimer  as  above  describeti,  always 
rememberino;  to  employ  tlie  utmost  care  and  gentleness, 
when,  as  a  rule,  the  instrument  will  find  its  way  into  the 
deeji  urethra  and  bladder,  with  only  a  reasonable  amount 


Fig.  56. — Tip  of  the  sound  iu  the  bladder.      (Original.) 


of  assistance  from  the  surgeon.  Quick,  rough,  and  unskilful 
instrumentation  invariably  leads  to  muscular  spasm,  which 
in  turn  means  difficult  or  even  impossible  instrumentation, 
and  may  result  in  a  prostatitis  or  even  ])rostatic  abscess. 
In  examining  old  men  tJie  tip  of  the  instrument  will  some- 
sometimes  catch  or  hitch  in  the  bulb,  as  in  these  cases  it  is 
often  in  a  more  or  less  relaxed  and  sacculated  condition, 


DIACNOSfS  OF  STincriHiK  149 

find  is  ciisily  cjirricd  on  llic  lip  of  llic  :^i»iiii(|  lor  ;i  -.liort. 
(list.llicc  ii|)\v;ir(i  ;uhI  l)ciic;itli  llic  iii(iiil»r;iiioiis  lirctlini. 
TJiis  (lifUciilty  can  be  easily  oKviatcd  hy  kccijiii^  tlic  tip 
of  the  instrument  in  close  contact  with  the  rooi'  of  the  ciinal; 
a  j)oint  wi)ich  a])i)lics  e(juall\'  well  1o  cases  of  [)o>1crior 
median  liyjxM-trophy  of  the  j)rostate  ^hiiid. 

If  the  flexible  bouf?ie  a  boule  deteets  a  strietiire,  we  must 
then  ascertain  its  exact  distance  from  the  meatus  and  its 
caliber.  The  bougie  having  been  j^asscd  down  to  the  ob- 
struction, the  distance  down  is  noted  by  holding  the  thumb 
and  finger  on  the  shaft  of  the  instrument  at  the  meatus; 
it  is  then  withdrawn,  when  the  distance  between  the  finger 
and  thumb  and  the  bulb  of  the  instrument  is  measured, 
which  gives  the  exact  depth  of  the  contraction  in  inches. 
Smaller  bougies  a  boule  are  tried  until  one  finally  passes 
the  obstruction,  which,  of  course,  gives  its  caliber  or  size. 

If  the  stricture  is  so  tight  that  it  will  not  admit  our  smallest 
olivary  bougie,  or  bougie  a  boule,  we  then  employ  whalebone 
filiform  bougies. 

In  passing  filiforms  it  is  best  to  keep  the  penis  on  the 
stretch  and  at  right  angles  to  the  body,  and  try  to  avoid 
the  lacuna  magna  on  its  roof,  in  which  these  little  instruments 
sometimes  catch.  The  tip  of  the  instrument  may  be  left 
straight,  or  turned  and  twisted  in  various  ways  and  shapes, 
as  already  shown.  The  urethra  having  been  injected  with 
a  solution  of  adrenalin  chloride  1  to  1000,  to  reduce  the 
congestion  of  the  mucous  membrane  o^•er  the  face  of  the 
stricture,  the  canal  is  then  fully  distended  and  lubricated 
with  warm,  sterile  olive  oil,  and  a  filiform  is  passed  down 
to  the  face  of  the  contraction,  and  rotated  slowly  and  care- 
fully until  it  engages  in  the  opening  of  the  stricture;  if  this 
does  not  occur  we  pass  another  filiform  alongside  the  first, 


150    ,  DIAGNOSIS  OF  STRICTURE 

and  so  on,  until  one  finally  enters  the  opening  in  the  con- 
traction and  passes  through,  when  it  is  left  in  situ  and  the 
others  removed.  If  tliis  is  impossible,  we  speak  of  it  as  an 
im])assable  stricture;  that  is,  im})assable  to  instruments, 
altliough  even  yet  the  urine  can  often  be  voided  in  drops 
or  even  in  a  fair-sized  stream. 

If  the  patient  has  such  an  abnormally  small  meatus  (IC  to 
18  French)  that  it  will  not  admit  bougies  or  sounds  of  a  suffi- 
cent  size  to  examine  the  urethra  properly,  and  if  it  is  not 
thought  wise  to  enlarge  the  meatus  at  the  time  by  meatotomy, 
then  we  may  employ  for  exploratory  purposes  the  Otis 
urethrometer  in  the  following  manner:  It  is  cleansed, 
lubricated,  gently  passed  into  the  bulb,  and  screwed  up  to 
about  No.  28  or  30  of  the  French  scale.  As  the  instrument 
is  slowly  and  gently  withdrawn  the  stenosed  areas  or  spots 
of  thickening  are  noted,  great  care  being  taken  not  to  diag- 
nose physiological  contractions  and  the  circular  muscular 
fibers  of  the  urethra  as  strictures,  which  mistake  can  easily 
be  made  if  the  examiner  o\'erexpands  the  bulb  of  the  instru- 
ment, or  if  he  is  unfamiliar  with  the  anatomy  of  the  canal. 


CHAPTER  XIV. 
TREATMENT  OF  STRICTURE. 

The  treatment  of  stricture  depends  entirely  ii})oi)  its 
cause,  situation,  and  extent,  and  whether  it  be  soft  and 
yielding,  or  dense  and  fibrous  in  character.  As  a  broad, 
general  rule,  however,  it  may  be  stated  that  the  best  routine 
treatment  for  the  majority  of  cases  of  gonorrheal  stricture  is 
gradual  dilatation  with  bougies  and  sounds  combined  with 
local  urethral  applications  and  internal  medication.  If  these 
methods  fail  or  cannot  be  employed,  we  are  then  compelled 
to  resort  to  one  of  the  cutting  operations  about  to  be  de- 
scribed. 

Traumatic  and  congenital  strictures,  being  fibrous  from 
their  incipiency,  do  not  yield  to  dilatation,  and  must  therefore 
be  treated  by  meatotomy,  urethrotomy,  or  perineal  section, 
according  to  their  location. 

The  urine  should  be  carefully  examined  in  order  to  ascer- 
tain the  condition  of  the  kidneys,  and  the  extent  and  severity 
of  the  urethral  and  bladder  inflammation,  if  these  conditions 
are  present. 

If  any  complications  exist,  they  must  be  treated  in  the 
manner  already  given  for  such  aflPections,  to  which  the 
reader  is  referred.  Kidney  disorders  are  to  be  handled  on 
general  medical  and  surgical  principles.  The  reaction  of  the 
urine  must  be  modified  either  by  the  administration  of 
urotropin  or  helmitol,  as  indicated,  and  the  patient's  diet 


l.")!'  Th'KATMKXr  OF  STRICT CRK 

c-aivt'ullx'  rcjiulatc'd,  x)  tliat  \vc  may  render  the  urine  as 
hland  and  noii-irritatiiiu'  as  ])ossil)le. 

Strictures  of  or  Near  the  Meatus.  Strietures  in  this  situa- 
tion do  not  yield  to  dihitation  and  nuist  therefore  l)e  eut 
(meatotomy).  The  normal  meatus  \aries  from  No.  21  to  2S 
French,  and  should  ne\er  he  interfered  with  unless  ahsolutely 
necessary,  as  overzealous  cutting  of  tliis  part  of  the  canal 
leads  to  a  flat,  spluttering  stream  that  cannot  be  thrown  any 
distance  from  the  body,  and  a  disagreeable  dribbling  of  urine 
after  each  act  of  urination,  also  a  feeble  and  unsatisfactory 
ejaculation,  of  which  some  patients  complain  bitterly.  If 
the  meatus  is  so  small  that  normal  urination  is  interfered 
with,  or  that  proper  treatment  cannot  be  applied  to  the 
parts  beyond,  then  it  may  be  cut  up  to  No.  28  or  even  32 
of  the  French  scale,  according  to  the  requirements  of  each 
individual  case. 

Strictures  of  the  Penile  Urethra. — Strictures  of  the  penile 
or  pendulous  urethra  include  all  of  those  contractions  which 
are  situated  between  the  meatus  and  the  j miction  of  the  penis 
with  the  scrotum.  If  these  contractions  are  soft  and  yielding, 
gradual  dilatation  should  be  tried  with  filiform  or  olivary 
bougies  or  the  steel  sound.  If  dilatation  causes  such  pain 
or  irritation  that  it  is  found  impracticable,  it  should  be 
stopped  and  the  stricture  cut  (internal  urethrotomy),  either 
with  a  straight,  blunt  bistoury,  if  near  enough  to  the  meatus, 
or  with  a  urethrotome,  if  further  down  the  canal.  For  a 
description  of  this  operation  the  reader  is  referred  to  page  158. 

Strictures  beyond  the  Penoscrotal  Junction. — For  strictures 
situated  in  the  bulbous  ])()rtion  of  the  urethra,  or  at  the 
bulbomembranous  junction,  that  are  soft  or  even  semi- 
fibrous,  we  should  always  try  gradual  dilatation  and  local 
urethral  medication  before  resorting  to  any  cutting  operation. 


INSTRUMENT.'^  153 

Should  (liliitiil  ion  Ijiil,  (he  slrieliuc  Is  llicii  cwi  l)_\'  cxtcni.tl 
urethrotomy. 

Gradual  Dilatation.  By  ,t;Ta(hial  (hlatation  is  iiicaiit  the 
^•('iitlc  |)assa<;('  of  Mhronii  bougies,  ohvary  hoiiji;i('s,  or  steel 
soiiiids  throiif^h  the  stricture,  the  seleetioii  of  the  (hhitiiij^ 
instrument  dependiiif^  ui)oii  the  size  or  ealilxr  of  the  eori- 
traetion,  which  was  ascertained  and  noted  at  the  time  of 
examination. 

Instruments. — If  the  stricture  is  under  IS  I^Vench,  we 
should  use  filiform  or  olivary  bou<^ies,  hut  if  IS  hVcnch  or 
over,  steel  sounds  should  be  employed. 

Gradual  dilatation  is  performed  every  fifth  or  seventh  day, 
depending  upon  the  reaction  and  results  obtained;  these 
can  be  noted  by  the  patient's  sensations,  and  the  appearance 
of  the  urine,  which  should  be  examined  at  each  visit. 

The  dilating  instrument  should  be  warm,  well  lubricated, 
passed  slowly  and  gently,  and  left  in  the  urethra  for  a 
minute  or  so,  in  this  manner  exerting  pressure  on  the  thick- 
ened and  infiltrated  urethral  walls,  which  in  many  cases 
resume  their  normal  consistency  as  the  result  of  the  absorp- 
tion of  the  inflammatory  material. 

The  size  of  the  bougies  or  sounds  must  be  increased  slowly 
and  guardedly  in  the  following  manner:  If  a  stricture  takes  a 
No.  15  French  at  the  first  visit,  the  surgeon  should  pass  at 
the  second  ^'isit  a  No.  15  and  16,  and  even  higher  numbers, 
provided  they  do  not  cause  too  much  pain  or  bleeding,  and 
so  on  until  he  has  reached  No.  28  or  32  of  the  French  scale, 
according  to  the  requirements  of  the  case. 

By  the  careful  employment  of  gradual  dilatation  combined 
with  local  urethral  medication,  many  cases  of  even  filiform 
stricture  may  be  dilated  up  to  No.  30  French  and  over, 
as  the  case  may  require,  and  be  kept  so  for  the  remainder  of 


154  TREATMENT  OF  STRICTURE 

the  patient's  life,  provided  he  will  have  a  sound  passed  a  few 
times  during  the  year, 

\\'hile  the  stricture  is  being  dilated,  the  urine  must  be 
kept  bland  by  a  carefully  regulated  diet,  and,  if  necessary, 
the  internal  administration  of  urotropin  in  full  doses,  with 
l)l(>nt\-  of  still  water.  Alcohol  in  all  forms  must  be  prohibited, 
and  si'xual  relations  refrained  from,  if  followed  by  irritation. 

Complications.^ — If  the  surgeon  is  hasty,  unskilful,  or 
uncleanly  in  his  urethral  manipulations,  he  may  cause 
such  complications  as  urethritis,  urethrocystitis,  epididy- 
mitis, prostatitis,  abscess  of  the  prostate,  false  passages, 
laceration  of  the  urethra,  with  urinary  extravasation,  urethral 
chills  and  fever,  or  retention  of  urine  from  swelling  of  the 
urethral  mucous  membrane  and  spasm  of  the  compressor 
muscle. 

If,  after  a  fair  trial,  gradual  dilatation  fails,  we  shall  then 
have  to  resort  to  urethrotomy,  either  external,  internal,  or  a 
combination  of  both,  depending  on  the  seat  and  extent  of  the 
strietured  area. 

Continuous  Dilatation. — By  continuous  dilatation  is  meant 
the  retention  in  the  urethra  for  several  hours  of  the  bougie 
or  filiform  that  has  been  passed  through  the  stricture.  As  a 
result  of  the  long-continued  pressure  of  the  retained  instru- 
ment some  strictures  yield  sufficiently  to  allow  of  the  volun- 
tary passage  of  urine,  and  also  of  larger  dilating  instruments. 
It  is  a  useful  method  in  certain  selected  cases  of  tight,  but 
soft  and  yielding  stricture,  if  the  patient  can  be  kept  in  bed 
and  be  carefully  watched. 

Rapid  Dilatation. — If  the  stricture  will  only  admit  a  filiform 
bougie,  it  may  be  left  in  place  and  used  as  a  guide  for  a  small 
tunnelled  sound  (Fig.  57),  which  consists  of  a  grooved, 
conical  steel  sound,  the  groove  terminating  in  a  canal  or 


kAPIJ)   DILATATION 


W, 


tunnel  at  its  vesical  (extremity,  tlirongh  which  the  filiform 
guide  piisses.     'J'hese  sounds  shoiil<l  run  from  ahout  Nf>.  0 


Fig.  57.  —  Gouley's 
tunnelled  sound  and 
filiform  in  place. 


Fig.   5S. — Kollman 
straight  dilator. 


Fig.  59. — Kollman 
curved  dilator. 


150  TREATMENT  OF  STRICTURE 

tt)  In  Fri'iicli.  iiiclii>i\ c,  ;iiiil  nuist  \)v  well  iniidc,  so  that  the 
edges  of  the  tuiiiiel  will  not  cut  the  hlit'orin  hoiiu'ic,  which 
should  pass  easily  through  it,  as  such  an  acci(hMit  may 
result  iu  the  loss  of  the  distal  fraguient  of  the  filiforui  iu  the 
posterior  urethra  or  bladder.  The  sound  is  ])assed  over  the 
filiform  guide  and  through  tlu>  stricture,  which  can  in  this 
nianuer  be  dilated  through  seAeral  sizes  at  oue  sitting,  ])ro- 
vided  it  is  soft  and  yielding,  the  subsequent  dilatation  being 
carried  out  with  bougies  and  sounds. 

This  method  of  rapid  dilatation  is  in  reality  a  form  of 
divulsion,  and  is  attended  with  more  or  less  risk,  even  in  the 
most  skilful  hands,  and  is  therefore  not  to  be  employed 
except  in  an  emergency,  and  unless  the  i)atient  can 
remain  in  ])ed,  with  ])roper  constitutional  and  local 
treatment. 

Divulsion. — The  treatment  of  stricture  of  the  urethra 
by  divulsion  with  si)ecially  constructed  straight  or  curved 
instruments  (dilators)  (Figs.  58  and  59)  is  dangerous,  inexact, 
and  rough,  as  compared  with  gradual  dilatation  and  the 
various  forms  of  urethrotomy,  and  sliould  therefore  never 
be  employed,  on  account  of  the  traiunatism  inflicted  on  the 
delicate  urethral  and  periurethral  tissues  which,  in  realitv', 
are  lacerated  and  torn,  with  the  subsequent  formation 
of  additional  cicatricial  tissue. 

Electrolysis. — As  electrolysis  is  only  of  questionable  serAice 
in  strictures  of  the  "soft"  variety,  it  is  merely  mentioned 
to  be  emphatically  condemned,  as  in  this  ^■ariety  most 
brilliant  results  are  obtained  by  gradual  dilatation,  and 
instillations  of  silver  Jiitrate.  It  has  no  effect  whatsoever 
upon  fibrous  or  innodular  strictures,  which  demand  free 
incision,  either  from  within  or  without,  de])ending  upon 
their    situation    in    the    canal. 


MKATOTOMY 


157 


Urethrectomy.  I'>y  iirctlirccloiiiy  is  iiic;iiit,  citlici-  tlu; 
partial  or  comijlete  resection  of  nil  of  tlic  stricture;  tissue 
at  the  time  of  an  external  urctlirotoiii\  or  perineal  section, 
and  the  hnildin^-  up  of  a  new  urethra,  sutured  nhout  a  retainerl 
soft-rul)her  catheter  or  tiihc.  (.See  discussion  of  external 
ur(>throtoiny,   i)aj;e   1(17.) 

Meatotomy. —  Hefore  jx-rfoi-niint;'  nieatotoniy  llic  patient 
urinates,  in  order  to  flush  out  the  canal,  and  lies  on  his 
back;  the  external  genitals  are  cleansed,  as 
is  also  the  urethra,  by  irrigations  of  warm 
boric  acid  solution,  and  the  parts  surrounded 
with  sterile  towels.  Local  anesthesia  may 
be  caused  by  injecting  a  little  2  per  cent, 
novocain  or  alypin  solution  into  the  urethra, 
which  produces  its  full  effect  in  about  ten 
minutes;  or  by  infiltrating,  by  hypodermic 
injection,  the  region  to  be  incised  with  a 
few  drops  of  one  of  these  solutions.  The 
prepuce  is  retracted  and  the  penis  grasped 
in  the  sulcus  behind  the  corona;  then, 
with  a  straight,  blunt  bistoury,  the  meatus 
is  slow^ly  incised  downward  on  its  floor 
and  directly  in  the  median  line  up  to 
about  No.  28  to  32  of  the  French  scale. 

Contractions  just  beyond  are  dealt  with 
in  the  same  manner,  except  that  a  little  cutting  may  have  to 
be  done  in  the  median  line  of  the  roof  of  the  urethra;  this  fact 
having  been  ascertained  at  the  time  of  the  first  examination. 

A  full-sized  meatus  sound  (Fig.  60)  is  then  passed  through 
the  meatus  to  see  that  all  is  clear,  and  the  passage  repeated 
daily  to  prevent  contraction  of  the  little  wound,  until  healing 
is  complete. 


Fic 


60. — Meatus 
sound. 


158  TREATMENT  OF  STRICTURE 

If  l)k'C(liiig  occurs,  it  can  be  readily  controlled  by  pressure 
witli  a  plug  of  gauze  and  a  light  gauze  dressing. 

Internal  Urethrotomy. — This  operation  consists  of  the  divi- 
sion of  the  stricture  within  the  lU'ethra,  the  incision  being 
made  on  the  roof  of  the  canal  and  directly  in  the  median 
line,  either  from  before  backward,  or  from  behind  forward, 
depending  upon  the  kind  of  urethrotome  employed,  thus 
producing  a  linear  wound.  When  the  operation  is  properly 
performed  there  will  be  little  or  no  danger  of  wounding 
either  of  the  corpora  cavernosa,  as  the  cut  is  situated  below 
and  between  them,  in  the  base  of  the  septum  pectiniforme. 

As  a  rule,  internal  urethrotomy  should  be  limited  to 
undilatable  strictures  situated  in  the  pendulous  urethra  and 
not  farther  down  the  canal  than  the  penoscrotal  junction, 
unless  it  is  combined  with  external  urethrotomy  for  the 
purpose  of  properly  draining  the  bulb. 

Instruments  for  Internal  Urethrotomy. — Instruments  for  this 
purpose  are  called  urethrotomes,  of  which  there  are  many 
forms  and  ^'arieties.  The  surgeon  shoukl  always  ha\e  two  or 
three  of  these  instruments,  as  no  single  one  is  adapted  to  all 
cases.  If  the  stricture  is  near  the  meatus,  it  may  be  nicely 
cut  with  a  straight,  blunt  bistourj'  or  a  Gouley  beaked  knife 
(Fig.  61). 

]\laisonneuve's  urethrotome  (Fig.  62)  consists  of  a  small 
groo\-ed  shaft  with  a  short  curve.  The  groove  carries  the 
blade,  and  is  situated  on  the  concave  surface  of  the  staff, 
stopping  at  the  point  where  the  curve  begins.  The  distal 
end  of  the  staff  has  a  screw  tip,  to  which  may  be  attached  a 
filiform  guide;  or  it  may  have  a  tunnelled,  or  a  solid  tip. 
The  blade,  fastened  to  a  long  stylet,  is  triangular  in  shape, 
sharp  in  front  and  behind,  l)ut  blunt  at  its  apex,  so  as  not  to 
cut  the  health V  urethra. 


INTERNAL   URETHROTOMY 


159 


Fig.  61. — Gouley's 
beaked  bistoury. 


Fig.  62. — Maisonneuve's 
urethrotome. 


f 


£ 


D 


Fig.  63.— Fluhrer 
urethrotome. 


160 


TREATMENT  OF  STRICTURE 


Thv  instriimcnt  is  iisod  as  follows:  Thi"  stall',  with  its  solid 
ti]),  is  i)assc'(l  into  the  hladdcr  and  lirld  Hrnily  in  the  median 
line  of  the  i)enis,  wJiich  is  j)ulled  forward 
on  the  streteh;  the  blade  is  then  slipped 
into  the  groove  and  pushed  down,  eiitting 
the  contractions  before  it;  it  is  then  with- 
drawn, the  j)enis  and  staff  being  held  in 
exactly  the  same  position. 

If  the  staff  cannot  be  introduced  alone, 
it  can  be  screwed  to  the  filiform,  wliich  it 
will  follow;  or  it  may  be  passed  oxer  a 
long  whalebone  filiform  lx)iigie  threaded 
through  the  eye  in  the  tunnelled  tip. 

The  Fluhrer  urethrotome  (Fig.  (53)  con- 
sists of  a  straight  Xo.  12  French  grooved 
stafi",  the  groove  for  the  knife  being 
situated  on  the  ui)per  surface  of  the  in- 
strument and  terminating  m  a  tunnelled 
ti]),  which  is  slightly  cu^rved  upward. 
The  blade  is  like  the  Maisonneuve  and 
cuts  to  about  Xo.  24  French.  A  whale- 
bone filiform  bougie  is  passed  into  the 
l)ladder  and  its  end  slipped  through  the 
tumielled  urethrotome,  which  is  intro- 
duced over  it  through  the  stricture.  The 
penis  is  held  on  the  stretch  in  the  median 
line,  the  knife  pushed  down  the  groove, 
and  the  stricture  cut  from  before  backward. 
The  Otis  urethrotome  (Fig.  (')4)  is  a 
dilating  and  cutting  instrument  combined. 
It  consists  of  two  steel  shafts,  wliich,  when  closed,  are  a})out 
Xo.  16  French;  these  shafts  are  connected  by  short  bars,  1  ke 


Tiu.   04. — Otis    lire 
thro  tome. 


INTKUNAL  iih'i<:'riii,'()'r()Mv  nil 

a  pariillcl  nilcr,  wliicli  ciiii  he  opciicd  ov  closed  \)\  iiiciiii-.ot  ;i 
screw  at  the  llJilidlc  of  llic  iiish-iiiiiciit ,  w  liirli  ;it  the  >;ili)<'  time 
indicates  on  m  little  index  the  caliber  to  wliicli  tliey  ;ire 
opened.  'i'Jie  blade  running  in  a  f^roove  in  tJie  upper  bar 
becomes  concealed  in  a  slot  when  it  reaches  its  extremity. 

The  instrument,  with  binde  concealed  in  its  tip,  is  jnissed 
just  beyond  the  stricture  and  gently  and  slowly  dilated  until 
the  stricture  feels  slightly  tense,  when  the  blade  is  drawn 
out,  cutting  through  the  stricture  on  the  roof  of  tlu'  can;d 
and  exactly  in  the  median  line,  and  from  behind  forward. 
The  blade  is  then  pushed  back  and  concealed,  the  shafts 
partially  approximated,  and  the  instrument  withdrawn. 

This  urethrotome  is  a  most  serviceable  instrument, 
provided  the  urethra  is  not  overdilated  and  unnecessarily 
incised. 

Internal  urethrotomy  having  been  decided  on,  the  urine 
must  be  examined  in  order  to  ascertain  the  condition  of  the 
kidneys  and  whether  the  bladder  or  urethra  is  the  seat  of 
inflammation.  If  diseased  conditions  exist,  they  must  be 
treated  on  the  lines  already  laid  down.  The  patient  is 
kept  very  quiet  in  the  house  for  twenty-four  hours  before 
the  operation  and  his  general  condition  carefully  attended 
to  in  every  detail.  Alcohol  in  all  forms  must  be  stopped  and 
the  urine  rendered  bland  by  a  light,  nutritious,  and  non- 
irritating  diet,  and  proper  internal  medication,  including 
urotropin  and  plenty  of  water.  The  bowels  should  be  freely 
opened  before  the  operation  and  kept  so  afterward.  If 
the  kidneys  will  not  allow  of  ether,  the  urethra  may  be 
anesthetized  with  a  little  2  per  cent,  alypin  solution,  or 
general  anesthesia  may  be  induced  by  nitrous  oxide  and 
oxygen. 

The  patient  having  urinated,  is  prepared  as  usual.  If 
11 


162    .  TREATMENT  OF  STRICTURE 

possible,  the  urethra  and  bhulcler  are  thoroughly  irrigated 
with  warm  boric  acid  solution  by  means  of  a  four-ounce 
hand-syringe  and  catheter,  and  the  cutting  performed  either 
with  a  straight,  blunt  bistoury,  if  near  enough  to  the  meatus, 
or  with  a  urethrotome,  if  further  down  the  canal. 

The  incision  with  the  bistoury  is  made  directly  in  the 
median  line  and  on  the  roof  of  the  urethra.  A  No.  28  to  32 
French  steel  sound  is  then  passed,  and  the  (li^•ided  con- 
traction kept  open  by  passing  sounds  every  other  day  until 
the  wound  is  healed,  when  the  inter\als  ])etween  instru- 
mentations can  be  made  nuich  longer. 

If  the  stricture  is  any  distance  from  the  meatus,  it  should 
be  divided  with  one  of  the  urethrotomes  just  described, 
and  which  is  most  suitable  to  the  case.  As  a  general  rule, 
it  is  safe  to  say  that  the  ]\Iaisonneuve  and  Fluhrer  ure- 
throtomes are  the  best  instruments  for  strictures  of  small 
cali})er,  while  the  Otis  instrument  is  serviceable  for  the 
larger  ones. 

The  stricture  having  been  cut,  the  urethrotome  is  taken 
out  and  a  full-sized  bougie  a  boule,  or  steel  sound,  should 
be  passed,  to  see  that  no  bands  or  constrictions  are  left, 
after  which  the  urethra  and  bladder  are  again  irrigated 
with  warm  boric  acid  solution,  several  ounces  of  which  are 
left  in  the  bladder  with  the  idea  of  diluting  the  urine  and 
rendering  it  less  irritating  as  it  is  voided  over  the  wound 
in  the  urethral  wall  after  the  operation. 

The  operation  being  completed  and  bleeding  controlled, 
the  patient  is  put  to  bed,  with  a  light  sterile  gauze  dressing 
around  the  penis. 

The  stricture,  having  been  cut  up  to  No.  28  or  32  French, 
is  kept  open  by  dilatation,  which,  with  urethral  and  possibly 
vesical  irrigation,  is  begun  on  about  the  second  day  after  the 


EXTERNAL  URETII UOTOMY  \^')A 

oijcratioii,  uiul  continued,  us  already  described,  (jaily  or 
every  other  day. 

If  internal  urethrotomy  is  performed  in  this  manner,  we 
will  not  have  such  unnecessary  complications  as  s(;vcre, 
and  sometimes  even  fatal,  hemorrhage,  urethral  chills  and 
fever,  permanent  curvature  of  the  penis,  etc.  In  this  opera- 
tion, no  matter  wdiat  instrument  is  employed,  it  should 
always  be  held  firmly  in  the  median  line;  and  the  penis 
pulled  out  over  it,  and  put  well  on  the  stretch  by  an  assistant 
so  that  the  incision  will  be  as  nearly  as  possible  in  the  median 
line  of  the  roof,  thus  avoiding  injury  of  the  corpora  cavernosa, 
with  subsequent  and  sometimes  profuse  hemorrhage. 

External  Urethrotomy. — For  strictures  situated  in  the 
bulbous,  the  bulbomembranous,  or  membranous  portion, 
we  should  perform  external  urethrotomy  or  perineal  section; 
the  object  of  the  external  cut  being  to  drain  the  bladder 
and  the  bulb  through  the  perineum,  and  in  this  manner 
prevent  the  accumulation  and  absorption  of  any  irritating 
or  infectious  secretion  that  might  occur  (urinary  fever). 

The  following  perineal  operations  are  for  bladder-drainage 
and  for  the  relief  of  strictures  of  the  bulbous,  the  bulbo- 
membranous, and  membranous  portions.  The  preparation 
of  the  patient  and  the  instruments  for  all  of  these  operations 
are  the  same,  and  to  prevent  repetition  will  be  described 
here,  and  not  with  each  special  operation. 

The  condition  of  the  kidneys  must  be  carefully  looked 
into,  by  uranalysis  of  the  twenty-four-hour  specimen,  and 
disease,  if  it  exists,  must  be  treated  on  the  usual  medical  or 
surgical  lines.  The  patient  is  kept  very  quiet  in  bed  for 
a  day  or  so  before  the  operation,  and  his  general  health  is 
put  in  as  good  condition  as  possible  by  a  light  diet  and  rest. 
Alcohol  must  be  stopped  and  the  urme  rendered  bland  and 


164 


TREATMENT  OF  STRICTURE 


non-irritatini];  by  the  administration  of  urinary  antiscjitios. 
The  liberal  use  of  any  pure  water  is  also  advisable  before 
these  operations. 

If  possible,  the   bladder  and   urethra  should   be  irrif^Mted 


Fig.  65. — Lithotomy  position  for  external  urethrotomy — scrotum  re- 
tracted to  expose  operative  field — staff  renders  urethra  prominfiit.  (.\uthor's 
case.) 

daily    with    warm  boric  acid    or    salt   solution  for  several 
days  before  the  operation. 

The  bowels  should  be  freely  moved  with  calomel  the  day 
prior  to  the  operation,  just  before  which  the  rectum  is 
cleansed  with  a  hot  saline  enema. 


KXTFJiNA  L    VlfETIIh'OTOMY 


H)o 


The  piiticiit,  hciii-,^  aiicstlicti/cd,  is  jjhifcd  Jn  il,,.  \\\\mAu\i\\ 
position  on  the  cxtrcinc  end  of  tlie  table,  on  a   Kelly  pad 
(Fig.  (if)).      'i'he  patient    nuist  he  in  a 
good  light,    and   held    there  flat  on   his 
back    and    exaetly    in    the    median    line 
by  leg-holders. 

All  asejitic  ])reeantions  are  obserxcd, 
as  in  any  operation. 

Kxtemal    Urethrotomy    icith  a  Guide. 
The  patient  being  prepared  for  opera- 
tion   and    anesthetized    as    already   de- 
scribed, the  anterior  urethra  is  injected 
with  a  drachm   or   two  of  (1  to  lOOO) 

adrenalin  chloride  and   then   distended 

with  warm,    sterile   olive   oil.     Then  a 

whalebone    filiform    bougie    is    passerl 

through  the  stricture  into  the  bladder. 
The  author's  tunnelled  staff  (Fig.  6(3) 

is  then  passed  over  the  filiform  to  the 

anterior  face  of  the  stricture  and  held 

there  exactly  in  the  median  line  by  an 

assistant,  who,  pressing  the  instrument 

downward,  renders  the  perineum  tense 

and    at    the    same    time    retracts    the 

scrotum,    thus  exposing   the   operative 

field  (Fig.  65). 

The  operator  then  cuts  down  on  the 

groove    on   the    convex   surface  of  the 

staff,    being    careful    not    to    cut    the 

filiform  guide  as   it   emerges   from   the 

tip  of  the  staff.    The  urethra  is  opened     grooved  and  tunnelled 

by  a  single  clean  incision,  which  thus     piace"""^  ^^'^°™  '° 


160     .  TREATMENT  OF  STRICTURE 

exposes  tlie   stall',   ami   the    lilit'orm    bougie    entering    the 
stricture   (Fig.   67). 

The  staff  is  now  withdrawn  and  the  filiform  drawn  down 
throu,i,^li  tlie  penis  and  out  of  the  perineal  wound,  its  distal 


Fig.  67. — Tip  of  staff  in  contact  with  anterior  face  of  stricture  and  filiform 
passing  through  it  into  bladder.     (Schematic  drawing.)      (Original.) 

end  remaining  in  the  bladder  through  the  opening  in  the 
stricture. 

An  Arnott  grooved  director  (Fig.  68)  is  now  passed  into 
the  bladder  by  the  side  of  the  retained  filiform,  which  is  then 
removed. 


EXTERNA  L   f/Rf'JTffROTOM  V 


](i7 


The  director  Ix-in^  firinl.y  held  in  the  mediiiii  line,  with  its 
groove  (hrectcd  upwiird,  ;i  })e;iked  })i.stoiiry  (Fig.  01)  is 
passed  in  its  groove,  and  the  stricture  cut  on  the  roof  of  the 
urethra;  the  bistoury  is  tlien  withdrawn,  the  probe  inverted 
so  that  its  groove  looks  downward,  and  the  stricture  incised 
on  the  floor  of  the  urethra  in  the  same  manner  as  on  the  rf)of. 


Fig.  68. — Arnott's  grooved  director. 

A  gorget  (Fig.  69)  is  now  passed  through  the  thoroughly 
divided  stricture  into  the  bladder,  from  which  the  urine 
flows. 

The  index-finger  is  now  passed  through  the  perineum  into 
the  bladder  to  see  that  all  stricture  tissue  is  thoroughly 


Fig.  69. — Teale's  gorget. 


incised  and  to  dilate  the  prostatic  sphincter  and  thus  prevent 
postoperative  spasm. 

In  some  cases  of  extensive  traumatic  stricture  in  which 
there  is  a  very  dense  form  of  scar  tissue,  it  may  be  necessary 
at  this  point  to  resort  to  urethrectomy,  ?'.  e.,  the  partial 
or  complete  excision  of  all  the  stricture  tissue,   with  the 


1.08 


TREATMENT  OF  smiCTrRE 


huildiiii;-  up  oi  a  iirw  urethra  l)y  suturiii.u-  toijjether  the 
divideil  ends  of  the  eaiial  al)()iit  a  retained  soft-rubber 
catheter. 


Fig.  71 


Fk;.  70  Fk;.  72 

Fig.  70. — Four  calculi  removed  from  pendulous  urethra  with  urethroscope. 
Actual  size.     (Author's  case.) 

Fig.  71. — Two  calculi  removed  from  bulbous  urethra  by  external  urethrot- 
omy.    Weight,  17  grains.      (Author's  case.) 

Fig.  72. — Calculus  removed  from  bulbous  urethra  by  external  urethrot- 
omy.    Weight,  49  grains.      (Author's  case.) 


Fig.  73 


Fig.  75 


Fig.  73. — Calculus  removed  from  bulbous  urethra  by  external  urethrot- 
omy.   Weight,  15  grains.      (Author's  case.) 

Fig.  74. — Calculus  removed  from  bulbous  urethra  by  external  urethrot- 
Weight,  26  grains.      (Author's  case.) 

Fig.  75. — Calculus  removed  from  bulbous  urethra  by  external  urethrot- 
omy.    Weight,  11  grains.      (Author's  case.) 


omy. 


The  deep  urethra  and  liladder  shf)uld  ahva\'s  ])e  explored 
\)\  the  index-finger,  as  in  these  cases  small  calculi  or  con- 
cretions are  sometimes  found  in  the  prostatic  urethra  or 


J'JXTl'JRNAL   l/h-l'yi'/lh'O'l'OM)-  Mi!) 

hl;i(l(l(T  (I^'ij^'s.  70  to  7"));  Ix-sidcs  wliicli,  tlic  fiii^^cr  pn^M'd 
into  the  l)l;i(l(l(T  dilates  tlic  prostatic  iintlira,  uliidi  i^ 
usually  contracted  in  these  eases,  tini>  prcx cntiim  in  i< 
great  measure  postoperative  teiiesniiis,  and  al-^o  detects 
any  stricture  tissue  tliat  has  not  \h-c]i  |)rop(rly  (h\  ided  on 
the  roof  of  the  canal. 

If  the  caliber  of  the  stricture  is  sufliciently  lar;,^'  to  permit 

of  the  passage  of  the  tunnelled   staff'  through    it  into  the 

bladder,  the  use  of  the  filiform  bougie  will  not  be  necessary, 

■  the  steps  in  the  operation,   with   this  exception,   liowever, 

being  the  same  as  those  outlined  abo\(>. 

The  finger  having  been  passed  into  the  bladder,  a  perineal 
tube  of  about  No.  30  to  35  French  (Fig.  70)  is  passed  over 


Fig.  76. — Otis's  perineal  drainage  tube. 

it  and  held  in  the  bladder  by  means  of  a  silk  suture,  wliich, 
being  passed  through  both  edges  of  the  wound  and  the  tube, 
is  securely  tied.  The  bladder  is  irrigated  with  warm  boric 
acid  or  salt  sohition,  which  is  thrown  in  by  means  of  a 
hand-syringe  or  irrigator  through  the  perineal  drain,  which, 
when  the  bladder  is  partially  filled  with  warm  solution, 
should  be  clamped,  to  retain  a  few  ounces  of  fluid  in  the 
bladder  until  drainage  is  established.  Bleeding-points  are 
caught  and  ligated,  the  wound  packed  with  sterile  gauze, 
and  the  dressing  held  in  place  by  a  firm  T-bandage.  When 
the  patient  is  put  to  bed  the  clamp  is  taken  off"  and  the 
perineal  tube  is  attached  to  a  piece  of  rubber  tubing  by  means 
of  a  glass  coupler  through  which  we  can  see  whether  the 


170 


TREATMENT  OF  STRICTURE 


bladder  is  tlraiiiiiig  properly  or  not.  The  tiihiiig  terminates 
in  a  bottle  under  the  bed  (Fig.  77),  wliich  is  one-quarter 
filled  with  1  to  1000  bichloride  solution;  this  keeps  the  urine 
which  runs  into  it  sweet,  and  prevents  the  entrance  of  air 
into  the  bladder.     If  the  tube  fails  to  drain,  it  may  be  due 


Fig.  77. — Perineal  drainage  of  bladder.     (Original.) 


to  the  plugging  of  the  eyes  with  clots,  which  can  be  dis- 
lodged by  injecting  the  tube  with  boric  acid  solution 
by  means  of  a  large  hand-syringe.  The  perineal  tube  is 
left  in  place  for  forty-eight  hours,  during  which  time  the 
bladder  may  be  irrigated  through  it,  once  or  twice  a  day, 
with  warm  boric  acid  solution.    The  anterior  urethra  should 


EXTERNAL   URETHROTOMY  171 

receive  similar  irri^Htioiis,  \(\vvm  i\\vin\\L\\  ;i  siiimII  sol't-ruMicr 
catheter. 

After  tlie  tube  is  removed,  lull-sized  s(juiids  mu.^L  be 
passed  daily,  at  first,  and  then  every  other  day,  followed  by 
bladder  and  urethral  irrigations,  the  j)atient  being  allf)\ved 
to  be  up  and  about.  When  the  perineal  wound  is  cicatrized 
the  interval  between  sounds  is  made  longer  and  the  chronic 
urethritis  is  treated,  as  already  described,  until  rnrcd. 
Even  then  these  patients  should  be  examined,  at  intervals 
of  a  few  months,  for  several  years  after  all  symptoms  have 
disappeared,  to  forestall  any  contraction  of  scar  tissue  and 
recurrence  of  the  stricture. 

■External  Zh-ethrotomy  without  a  Guide. — This  operation 
is  employed  in  cases  that  will  not  admit  of  the  passage 
of  an}^  instrument  through  the  stricture. 

The  patient  is  prepared  and  placed  on  the  operating  table, 
as  above  described,  and  a  last  attempt  made  to  enter  the 
bladder  under  general  anesthesia. 

This  failing,  a  Hayden  staff  is  passed  down  to  the  anterior 
face  of  the  stricture,  with  its  groove  toward  the  perineum, 
and  held  there  by  an  assistant,  who  at  the  same  time  retracts 
the   scrotum. 

The  operator  cuts  down  on  the  staff,  through  the  perineum, 
opening  the  urethra,  on  the  groove  of  the  instrimient,  just  in 
front  of  the  stricture;  the  cut  edges  of  the  urethral  wound 
are  then  retracted  by  Allis's  clamps  (Fig.  78). 

The  staff  is  now  withdrawn  and  the  divided  urethra  held 
well  open  with  the  clamps.  The  operator  now  has  a  clear 
view  of  the  anterior  face  of  the  stricture.  This  is  carefully 
examined  for  its  opening  by  means  of  a  whalebone  filiform 
or  Arnott's  grooved  director,  which,  if  possible,  is  passed 
through  it  into  the  bladder. 


172 


TREATMENT  OF  STRICTURE 


The  strictiiiH'  is  (li\i(UMl  with  (imilcys  ht'jiked  bistoury  on 
the  director,  as  described  in  the  previous  operation,  and  the 
index-fiujjer  is  ])assed  to  the  bladder  for  dilatation  of  the 
prostatic  urethra,  ex|)loration  of  the  i)lad(ler,  and  to  ascertain 
if  all  of  the  stricture  tissue  has  been  c()nii)letely  dix'ided.  A 
full-sizetl  sound  is  now  passed  from  the  meatus  to  the  bladder 
to  see  that  no  contraction  has  been  left. 

The  drainage,  dressing,  irrigation,  and  ])Ostoperative 
dilatation  are  the  same  as  in  the  ])erineal  oj)eration  above 
detailed. 


Fig.  78. — AUis's  clamp. 


If  the  opening  in  the  stricture  cannot  be  found,  the  surgeon 
will  then  huxe  to  complete  the  operation  without  a  guide, 
cutting  through  the  stricture  slowly  and  carefully  in  the 
median  line,  with  perhaps  the  index-finger  of  the  left  hand  in 
the  rectum,  which,  i)ressing  uj)  against  the  membranous 
urethra,  keeps  the  operator  informed  as  to  the  proximity 
of  the  rectum  and  the  position  of  the  apex  of  the  prostate 
gland,   both   of   which   are   valuable   landmarks. 

This  part  of  the  operation  will  be  much  simjjlified  by 
keeping  the  operative  field  thoroughly  .sponged,  and  the 
urethral  wound  well  retracted,  so  that  the  surgeon  can  see 
the  ])rogress  he  makes.  The  application  of  a  solution  of 
adrenalin  (1  to  ]()()())  is  often  useful  to  prevent  obsciu'ing 


i<:xTi<:i{NAL  ('u/'j'nih'o'i'oM )  17:'. 

of  tilt'  opcrjil i\('  field  \>\  oo/.iii;^'  of  Mood.  Tlic  .^1  lining  iiiih-oii~, 
membrane  of  the  roof  of  the  iirethr;i  is  also  a  s(T\iee;d)le 
guide,  as  it  can  he  plaiiil.N-  seen  ;ind   fell. 

Perineal  Section,  '{lu^.  operation  is  |jerl'ornie(|  in  those 
exceptional  cases  which  will  not  admit  of  the  passage  of 
any  instrnnient  throngh  the  anterior  nrethra.  It  is  there- 
fore done  without  a  guide,  and  is,  at  best,  a  \-ery  difheiilt 
and  oftentimes  tedious  procedure. 

The  usual  preparations  for  perineal  operation>  ha\ii)g 
been  made,  the  surgeon  makes  a  last  attempt  to  jjass  a 
filiform  guide  under  ether,  which,  if  accomplished,  con- 
verts the  difficult  perineal  section  into  a  simple  external 
urethrotomy. 

The  steps  in  the  operation  are  as  follows:  The  index- 
finger  of  the  left  hand  is  introduced  into  the  rectum,  and 
its  tip  kept  in  contact  with  the  apex  of  the  prostate  gland. 
A  free  incision  is  made,  layer  by  layer,  in  the  median  line 
of  the  perineum,  down  toward  the  anus,  in  the  endeavor 
to  open  the  urethra  just  at  the  apex  of  the  prostate;  or  the 
operator  can  cut  down  to  the  urethra  by  careful  dissection, 
as  in  an  ordinary  external  urethrotomy. 

The  urethra  having  been  found  and  opened,  a  fine,  probe- 
pointed  director  is  now  passed  through  the  perineal  wound 
into  the  bladder,  which  should  be  explored  by  the  index- 
finger,  and  all  of  the  stricture  tissue  thoroughly  divided,  not 
only  on  the  floor,  but  also  on  the  roof  of  the  canal,  as  in  an 
ordinary  external  urethrotomy. 

The  drainage  and  the  subsequent  treatment  are  precisely 
the  same  as  described  in  the  other  perineal  operations. 

The  anterior  stricture  or  strictures  are  di\ided  by  imme- 
diate internal  urethrotom\-. 


174     .  TREATMENT  OF  STRICTURE 

Rcirofiradr  Cathctcrhai'wn.- — If  it  is  impossible,  as  it  very 
rarely  should  be,  to  find  the  urethra  and  to  enter  the  bladder 
by  the  perineal  route,  then  the  surgeon  may  i)erform  supra- 
pubic cystotomy,   and,   guided    by    the  index-finger  in  the 


Fig.  79. — Urethroperineal  fistula.     (Author's  case.) 

bladder,  pass  a  silk  bougie  through  the  siuall  sui)rapubic 
incision  into  the  vesical  orifice  of  the  urethra,  down  through 
its  prostatic  portion,  and  out  into  the  j)erineal  wound,  thus 
locating  the  proximal  end  of  the  canal. 
This  method  may  have  to  be  employed  in  some  old  and 


EXTKUNAL   U h'l<:Tll h'OTOMY  lib 

neglected  cases  of  stricture,  iji  wliidi  the  urethra  is  con- 
verted into  a  fil)r()us  cord,  llie  urine  escaping  by  fistulous 
tracts  which  open  on  the  scrotum,  f)Uttocks,  a})fJornen,  or 
thighs  (Fig.  79),  also,  in  cases  of  extensive  laceration  or 
rupture  of  the  urethra,  caused  by  blows  or  falls  on  the 
perineum,  either  with  or  without  fracture  of  the  pelvis. 

In  these  traumatic  cases  the  tissues  are  sometimes  so 
lacerated  and  filled  with  ])loo<l-elots  that  it  may  be  very 
difficult  or  impossible  to  find  the  })r()ximal  end  of  the  urethra. 
This  must  always  be  done  in  order  to  drain  the  bladder, 
and,  if  so  desired,  to  approximate  with  fine  sutures  the  ends 
of  the  injured  canal,  through  which  a  soft-rubber  catheter 
is  passed  to  the  bladder  and  retained  there  until  the  urethral 
wounds  have  cicatrized.  This  will  in  a  great  measure  pre- 
vent the  formation  of  traumatic  or  postoperative  stricture. 

The  urethra  may,  however,  be  left  to  granulate  with  the 
bladder  drained,  and  the  case  treated  as  above  described 
under  external  urethrotomy  for  stricture;  the  choice  of 
procedure  resting  entirely  with  the  operator. 


CHATTKR   X\-. 

RETENTION  OF  nUNK. 

IIktextiox  of  iiriiR'  may  occur  during  tho  course  of 
acute  gonorrhea,  from  spasm  of  the  compressor  urethrae 
muscle,  caused  by  the  intense  inflammation  in  the  hull), 
prostate,  or  prostatic  urethra.  It  may  also  he  due  to  oc- 
clusion of  the  canal  from  a  periurethral  abscess,  or  one  of  the 
prostate,  or  of  Cowper's  gland.  After  ru])ture  or  evacuation 
of  the  abscess  there  is  free  and  spontaneous  urination. 
Retention  is  also  a  frequent  complication  of  stricture  of  the 
urethra,  the  mucous  membrane  covering  which  becomes 
suddenly  swollen  and  congested  from  alcoholic  or  sexual 
excesses,  catching  cold,  bodily  fatigue,  irritating  urine,  etc. 
(Hg.  80).  Retention  of  urine  is  of  frecjuent  occurrence 
after  surgical  operations  on  the  perineum,  genitals,  rectum, 
anus,  appendix,  and  hernite,  etc.,  being  due,  in  these  cases, 
to  spasm  of  the  compressor  urethra^  muscle.  In  cases  of 
l)rostatic  hypertrophy,  retention  frequently  follows  mild 
excesses  in  eating  and  drinking,  sexual  excitement,  exposure 
to  cold,  or  overexertion,  or,  in  fact,  anything  that  tends 
to  congest  the  mucous  membrane  of  the  prostatic  urethra 
and  tIic  i)rostate  itself.  These  ca.ses  may  be  associated  with 
compressor  spasm  caused  by  the  ])rostatic  irritation.  It 
occurs  not  infrequently  during  the  course  of  typhoid  fever 
and  similar  long,  exhausting  diseases.  Other  less  frequent 
causes    are   transverse    myelitis,    impacted    urethral    calculi 


TUI'JATMf'JNT 


177 


(I^'if^'S.   70   to   7")),   (•()ii<i,-ciiit;iJ   striciiirc  of   llic   iiiciil  ii-;,   jiml 
marked  congenital  phiinosis. 

As  a  result  of  acute  urinary  retention,  then;  is  at  first  a 
mild  congestion  of  the  bladder  mueons  membrane,  wliieli 
condition,  if  not  relieved,  is  soon  followed  by  intense  con- 
gestion of  the  entire  urinary  tract,  thus  rendering  it  ripe 
for  infection,  should  microorganisms  be  introrlueed  on 
catheters,  aspirating  needles,  or  examining  instruments. 
Therefore,  when  treating  these  cases,  we  should  avoid  trauma- 


FiG.  80. — Retention  of  urine  due  to  stricture.    Bladder  distended  with 
90  ounces  of  urine  (2700  c.c).     (Author's  case.) 


tism  of  the  congested  mucous  membrane,  b\'  careful  and 
gentle  instrumentation,  and  be  absolutely  clean  as  to  liands, 
lubricant,  instruments,  and  the  external  genital  organs. 
Urinary  antiseptics  should  always  be  administered,  and 
care  should  be  taken  to  prevent  o\erdistention  of  the 
bladder    (Fig.    80). 

Treatment. — If  retention  occurs  during  the  course  of  an 

acute  gonorrhea,  the  patient  should  be  put  in  a  hot  sitz  bath. 

Hot  water  or  hot  saline  solution,  at  116°  F.,  may  aJso  be 

injected  into  the  rectum.     If  these  means  fail  to  relieve  the 

12 


ITS  RETENTION  OF   URINE 

spasm  and  congestion  in  and  aliont  the  nrctlira,  the  patient 
must  be  catheterized  with  a  nu'dinni-si/cd  s()t't-rnt)l)i'r  cath- 
eter. Should  a  more  rigid  instrument  be  required,  we  may 
then  use  straight  blunt  or  olivary  pointed  silk  catheters 
(Figs.  81  and  82),  which,  although  firm,  are  very  flexible 
and  readily  adapt  themselves  to  the  urethral  curves.  The 
glans  and  j^repntial  cavity  are  washed  with  1  to  1  ()()()  bi- 


FiG.  81.— Straight  blunt  silk  catheter. 

chloride  solution,  and  a  sterile  catheter,  well  lubricated, 
is  passed  slowly  and  gently  down  to  and,  if  j^ossible,  beyond 
the  obstruction,  the  urethra  being  gently  irrigated,  if  so 
desired,  with  warm  boric  acid  solution  as  the  catheter 
glides  slowly  down  the  canal.  After  the  bladder  has  been 
slowly  emptied  a  few  ounces  of  the  warm  medicated  solution 
should  be  left  in,  when  the  catheter  is  withdrawn. 


Fig.  82. — Straight  olivary  silk  catheter. 

^Vhen  retention  is  caused  by  stricture  of  the  urethra  we 
may  first  try  the  hot  bath  and  hot  rectal  injections,  which 
in  some  eases  are  successful;  if  they  fail,  however,  we  then 
resort  to  gentle  and  sterile  catheterization,  using  any  of 
the  instruments  above  described  for  this  pnri)()se.  If  we  are 
still  luisuccessful  in  reaching  the  bladder  the  urethra  is  then 
injected  full  of  sterile  adrenalin  chloride  sohition  (1  to  lOOO), 
which  is  held  in  the  urethra  for  five  minutes.     This  will 


TREATMENT  170 

sometimes  so  reduce  the  con^a'slion  iind  suclliiif,'  of  the 
limcoiis  iiicinhniiic  ;is  to  permit  of  the  passage  of  ;i  e;itlieter. 
Should  this  fail,  we  nuiy  tlien  distend  the  urethni  t)y  injecting 
warm  sterile  olive  oil,  which  is  retained  by  conijjressiiig 
the  meatus,  and  several  filiform  bougies  are  passed  sueees- 
sively  down  to  the  l.wv  of  the  strieture,  the  pciii^  being  held 
on  the  streteh  and  at  right  angles  to  the  body.  Ivich  fili- 
form is  tried  in  turn,  until  one  finally  j>asses  the  stricture 
and  enters  the  bladder;  this  one  is  always  left  in  and  the 
others  removed.  The  filiform  that  has  entered  the  bladder 
ean  be  retained  by  tying  it  in  with  a  pieee  of  strong  waxed 


A  Q 

Fig.  S3. — Filiform  liougie  tied  in  the  urethra.      (Original.) 

thread  or  silk  (Fig.  S3),  which  is  first  tied  securely  about  the 
filiform  as  it  emerges  from  the  meatus  (.4),  then  knotted 
about  an  inch  from  this  point  {B),  and  the  two  long  ends 
brought  around  in  the  sulcus  behind  the  corona,  and  tied 
in  a  bow  knot  on  the  dorsum  {C)\  if  the  penis  becomes 
erect  the  knot  can  be  loosened.  In  a  short  time,  as  a  result 
of  this  continuous  dilatation,  the  urine  may  begin  to  drilible 
out  along  the  side  of  the  retained  filiform,  but  this  is  not 
always  the  case.  Using  this  filiform  as  a  guide,  we  may  pass 
either  a  tunnelled  silver  catheter  (Fig.  84)  over  it  and  draw 
some  of  the  urine,  or  several  sizes  of  tunnelled  sounds,  and 


180    .  RETENTION  OF   URINE 

in  this  manner  dilate  the  stricture  rapidly.  If  deemed 
advisable  at  this  time,  the  surgeon  should  perform  external 
or  internal  urethrotomy,  or  a  combination  of  both,  depending 
on  the  site  of  the  stricture  and  the  requirements  of  the  case, 
using  the  filiform  as  a  guide,  and  in  this  maiuier  relieving 
the  retention  and  cutting  the  stricture  at  one  sitting. 

Occasionally  it  may  be  possible  to  pass  a  filiform  through 
the  stricture,  even  when  the  method  described  above  has 
failed,  by  passing  an  endoscopic  tube  down  to  the  face  of 
the  contraction.  This  procedure,  by  dilating  the  urethra 
and  smoothing  out  the  folds  over  the  face  of  the  stricture-, 
permits  the  operator  to  locate  visually  the  opening  in  the 
contraction  and  to  introduce  the  filiform  guide  through  it. 


G.  TieMA/VN  &  CO. 

Fig.  8-i.- — Gouley's  tunnelled  catheter  and  guide. 


If  this  plan  also  fails,  and  the  case  demands  it,  we  must 
then  resort  to  suprapubic  aspiration  of  the  bladder,  passing 
the  needle  through  the  space  of  Retzius  and  anterior  bladder 
wall,  which,  fortunately,  is  not  covered  by  peritoneum  when 
that  viscus  is  distended  with  urme. 

Aspiration  is  performed  as  follows:  The  patient  is  placed 
on  his  back  and  the  operative  field  shaved,  rendered  sur- 
gically clean,  and  surrounded  with  sterile  towels;  a  few 
drops  of  a  1  per  cent,  solution  of  noA'ocain  or  cocain  are 
then  injected  beneath  the  skin,  directly  in  the  median  line 
and  just  above  the  symphysis;  the  integument  over  this 


TREATMENT  181 

spot  is  incised  for  ahoiit,  ii-  ([uartcr  of  ;iii  iiH'li,  the  jmtlior's 
trocar  and  cannula  (Fig.  85)  thrust  downward  througli  the 
little  incision  into  the  bladder  and  part  of  tlu;  urine  drawn, 
after  which  a  little  warm  boric  acid  solution  should  be  thrown 
into  the  bladder  through  the  outflow  tube  of  the  cannula 
by  means  of  a  hand-syringe  and  rubber  coupler,  so  as  not 
to  relieve  the  pressure  too  suddenly,  by  completely  emptying 
the  viscus.  The  cannula  is  then  removed,  and  the  little 
puncture  covered  with  a  pad  of  sterile  gauze. 

If  the  retention  is  due  to  prostatic  hypertrophy  and  the 
patient  is  not  in  too  much  distress,  we  should  first  try 
hot  sitz  baths  and  rectal  irrigations,  as  already  described, 


Fig.  85. — Author's  trocar  and  aspiration  cannula. 

especially  if  it  is  the  first  attack  the  patient  has  ever  had, 
as  in  such  cases  the  urine  is  usually  clear,  instruments  never 
having  been  passed,  and  infection  is  therefore  very  liable 
to  occur  from  traumatism  of  the  congested  prostatic  urethra 
and  bladder  base.  These  means  failing,  we  may  then 
resort  to  careful  catheterization  under  aseptic  precautions, 
as  before  described;  we  may  use  olivary  or  plain  silk  or 
rubber  coude  catheters  (Figs.  86  and  87),  or  silk  bicoude 
catheters  (Fig.  88).  The  angle  in  these  instruments  enables 
them  to  rise  over  the  bar  or  posterior  median  enlargement  of 
the  prostate,  which  is  situated  on  the  floor  of  the  vesical 
orifice  of  the  urethra.     It  is  alwavs  best  in  these  cases  to 


182 


RETENTION  OF   URINE 


Fig.  SG.  —  Olivary 
pointed  silk  coude 
catheter. 


Fig.  87.  —  Soft- 
rubber  coude  cathe- 
ter. 


Fig.  88.  —  Silk  bi- 
coudc  catheter. 


ri{i<:.\TMi<:NT  183 

try  llic  sot't-nihhcr  iiislriinicnls  first,  ;is  tlicy  iirc  less  liiiMc 
to  produce  trauinatisiii,  wliicli  is  the  first  step  toward 
urinary  infection  witli  its  trjiin  of  distressing  anrl  dangerous 
sequela'.  If  the  hiadder  cannot  he  entered  with  any  rjf  the 
above  instruments,  then  a  siilver  catheter  with  jirostatic 
curve  (Fig.  89)  may  be  employed,  the  surgeon  always 
bearing  in  mind  the  traumatism  that  this  rigid  and  unyielding 
instrument  is  liable  to  produce  even  in  trained  hands.  If 
catheterization  is  impossible,  the  patient  must  })e  aspirated 
above  the  pubes  as  already  descril)ed. 


Fig.  89. — -Silver  catheter  with  prostatic  curve. 

In  all  cases  of  retention  of  urine,  but  especially  in  those 
due  to  hypertrophy  of  the  prostate  gland  and  old  and  tight 
urethral  stricture,  great  care  should  be  taken  never  to  draw 
all  of  the  urine,  as  the  sudden  and  complete  evacuation  of 
the  bladder,  especially  in  prostatics,  is  very  liable  to  be 
followed  by  severe  shock  and  suppression,  or  by  brisk 
hemorrhage  in  the  kidneys,  bladder,  or  both,  owing  to  the 
sudden  removal  of  pressure  from  the  kidneys  and  bladder 
wall.  If  by  some  mistake  the  bladder  has  been  completely 
emptied,  then  several  ounces  of  a  warm,  sterile,  boric  acid 
or  salt  solution  should  be  thrown  into  the  bladder  through 
the  catheter  or  cannula  and  left  there.     As  the  urine  is 


184  RETENTION  OF   URINE 

slowly  withdrawn  it  must  he  partially  replaced  by  a  warm, 
sterile,  and  non-irritating  solution. 

In  any  case  of  retention,  no  matter  what  the  cause  may  be, 
all  instrimicntation  of  the  urethra  should  cease  as  soon  as 
there  is  nuicli  bleeding  from  the  meattis,  as  this  shows  that 
the  mucous  membrane  has  been  damaged  and  false  passages 
])robably  i)roduced;  catheterization  at  this  time  is  futile, 
and  should  therefore  be  abandoned  for  the  hot  bath,  aspira- 
tion, and  rest  in  the  recumbent  position,  or,  this  failing, 
immediate  perineal  or  suprapubic  drainage.  Should  the 
patient's  general  condition  warrant  it,  a  prostatectomy  or 
urethrotomy  may  be  ])erf()rmcd  at  this  time,  as  indicated, 
although  in  the  majority  of  cases  these  operations  should 
be  deferred  imtil  drainage  has  ])een  established  for  some 
time  and  the  functionating  powers  of  the  kidneys  ascer- 
tained. 


CHAPTER  XVI. 
URINARY  FEVER. 

Urinary  fever,  also  known  as  catheter  fever,  urethral 
fever,  urinary  poisoning,  and  urinary  infoftiou,  may  follow 
any  of  the  various  operations  or  instrumental  procedures 
on  the  urethra  and  bladder,  especially  in  those  cases  in  which 
the  mucous  membrane  is  lacerated,  the  urine  septic,  and  the 
kidneys  damaged. 

Patients  are  occasionally  met  with  in  whom  the  easy  and 
gentle  passage  of  clean  urethral  instruments  is  followed  by 
pallor,  faintness,  and  even  complete  loss  of  consciousness; 
this  is  merely  a  reflex  nervous  phenomenon  which  is  in  no 
way  connected  with  true  urethral  infection. 

There  are  two  main  varieties  of  urethral  fever,  as  follows: 

In  the  first  variety  there  is  a  slight  rise  in  temperature, 
coming  on  after  urethral  operation  or  instrumentation,  and 
preceded  or  accompanied  by  chilly  sensations  or  a  decided 
chill.  These  patients  feel  hot,  uncomfortable,  and  restless 
for  a  short  time,  after  which  they  are  perfectly  well. 

The  second  variety  is  more  severe;  the  chill  is  sudden, 
well  marked,  and  prolonged,  followed  by  a  rise  in  tem- 
perature (sometimes  as  high  as  105°  F.  or  over),  profuse 
sweating,  and  general  depression  of  the  vital  forces.  This 
severe  form  may  recur  with  each  attempt  at  urethral  in- 
strumentation, and  is  often  accompanied  by  partial  or 
even  total  suppression  of  urine.     These  patients  are  in  a 


.186  URINARY  FEVER 

critical  condition,  as  their  kidneys  arc,  as  a  rule,  more 
or  less  iliseased. 

The  etiology  of  tirinary  i'e\cr  is  hactcrial  infection,  the 
most  common  orjianisnis  being  the  colon  bacillus,  staphyl- 
ococcus, and  stri'ptococcus.  It  is  therefore  more  apt  to 
occur  and  to  be  more  severe  in  i)atients  with  daman'cd 
kidneys,  septic  urine  and  lacerated  bladder  and  urethral 
mucous  membrane,  from  which  septic  absorption  can  take 
place. 

In  order  to  gtiard  against  urethral  fever  we  must  be 
absolutely  aseptic  in  all  of  our  operative  procedures  and 
instrumental  examinations  on  the  gcnito-urinary  tract,  and 
endeavor  not  to  produce  lacerations  or  al)rasions  of  the 
bladder  or  urethral  mucous  membrane  by  overzealous 
and  rough  instrumentation.  Urotropin  in  full  dose  should 
always  be  administered  before  and  after  instrumentation, 
with  copious  draughts  of  water. 

Treatment. — The  patient  is  kei)t  in  bed  and  the  bowels 
freely  moved  with  calomel  and  saline  in  liberal  dose.  Alcohol 
baths  will  add  to  the  patient's  comfort.  Cardiac  stimulants 
and  tonics,  such  as  quinin  and  strychnin,  are  administered 
if  indicated.  Should  there  be  any  sign  of  suppression  of 
urine  we  must  immediately  order  dry  cups  over  the  kidneys 
and  hot-air  liaths,  or  hot  packs,  with  diuretin,  or  caffein- 
sodium-salicylate,  tincture  of  digitalis,  sweet  spirits  of  nitre, 
and  liberal  amounts  of  water.  Hot  normal  salt  solution  is 
of  great  ser^•ice  in  some  of  these  cases,  and  may  be  ad- 
ministered either  by  infusion  into  the  median  basilic  vein, 
subcutaneously  with  a  small  aspirating-needle  (hypo- 
dermoclysis),  or  injected  into  the  recttnn.  If  there  are  any 
operative  wounds  of  the  urethra,  they  must  be  kept  clean 
by  irrigation  with  sterile  boric  acid  solution,  and  the  urine 


TREATMENT  187 

drawn  with  sterile  e;illie1ers,  or  I  he  Madder  dniined  l»y 
perineal  or  sti])rii|)iil)ie  ineisioii,  or  the  retained  or  iiiflwellin^ 
catheter.  liorie  acid,  heii/,oat(!  of  so(hi,  iirotropiii,  or  liel- 
niitol,  fi;iv('ii  internally  and  in  I'nII  dose,  lia\('  marked  eflV'ct 
on  tlie  urine,  and  should  therel'ore  he  employed. 


CHAPTER  XVII. 

T'lIKTIIlJAL  INSTUrMENTS:    T1IKI1{    CAIIK   AND 

USE. 

Before  taking  uj),  in  detail,  tlic  discussion  of  the  prepara- 
tion and  nianipnlation  of  the  various  in(hvi(hial  instruments 
used  in  urologieal  work,  we  must  consider,  for  a  moment, 
the  general  principles  which  go\'ern  their  use. 

It  must  be  remembered  that  in  the  great  majority  of  cases 
demanding  urethral  examination  and  treatment  the  mucous 
membrane  is  congested  and  more  or  less  irritated  and 
infected.  It  is  imperative,  therefore,  that  all  instruments 
coming  in  contact  with  it  be  absolutely  sterile,  and  that 
their  surfaces  be  smooth,  highly  polished,  and  non-irritating. 
Also  that  the  surgeon  be  so  careful,  gentle,  and  skilful  in  his 
instrumental  manipulations  that  he  does  not  cause  contusions, 
abrasions,  or  lacerations  of  the  mucous  membrane,  over  which 
purulent  urine  subsequently  flows,  the  septic  material  from 
which,  being  absorbed  by  the  wounded  mucous  membrane, 
is  very  apt  to  give  rise  to  alarming  and  even  fatal  mani- 
festations; this  point  is  of  paramount  importance  and  is 
not  always  sufficiently  appreciated.  We  should  always 
remember  that  traumatism  is  the  first  step  in  urinary 
infection. 

The  examiner  must  never  forget  that  extreme  gentleness 
is  of  as  much  importance  as  the  proper  cleansing  of  his 
instruments,  and  that  many  of  the  methods  advocated  for 
this  latter  purpose  with  formalin,  formaldehyde,  etc.,  are 


SILK  OJJVAItY   BOUGIES   AND  BOUdIKH  A    BOIILE     ISO 

liable  to  render  the  surface  of  flexiMc  instminents  so  rotif^li 
and  irritating  to  the  urethral  mucous  inenihrane  that  they 
are  really  unfit  for  practical  use,  although  from  a  laboratory 
standpoint  they  may  be  absolutely  sterile  anrl  harmless. 
If  instruments  have  been  sterilized  in  this  nijiinicr,  they 
should  always  be  dipped  in  a  sterile  boric  acid  solution 
and  their  surfaces  tested  prior  to  use,  in  order  to  prevent 
urethral  and  bladder  irritation. 

Sounds  should  be  kept  separate  from  each  other  to  prevent 
scratching  or  denting  of  their  nickel-plated  surfaces,  whic-h 
ought  always  to  be  intact,  smooth,  and  highly  polished. 
When  passed  on  a  patient  they  should  be  washed  with  soap 
and  hot  water,  dried  on  sterile  gauze,  and  dipped  up  to  the 
handle  in  alcohol,  which  is  then  lighted  and  allowed  to  burn 
off;  or  after  washing,  the  sound  may  be  boiled  for  a  few 
minutes  in  a  2  per  cent,  carbonate  of  soda  solution  (to  pre- 
vent rusting),  or  plain  water,  if  this  method  be  preferred 
to  the  flaming  process.  The  sound  can  now  be  cooled,  if  so 
desired,  by  dipping  it  in  cold  sterile  water  or  boric  acid 
solution. 

Tunnelled  sounds  are  prepared  in  the  same  manner  as 
ordinary  sounds,  great  care  being  taken  to  render  the 
tunnelled  portion  and  groove  clean,  with  a  stiff  nail-brush 
and  plenty  of  soap  and  hot  water,  before  the  instrument 
is  subjected  to  the  flaming  or  boiling  process. 

Endoscopic  tubes  must  be  very  carefully  washed  inside 
and  outside  with  hot  soapsuds,  dried  on  gauze,  and  then 
flamed  oft'  with  alcohol;  or  boiled  in  soda  solution;  their 
obturators  are  cleansed  in  a  similar  manner. 

Silk  Olivary  Bougies  and  Bougies  a  Boule. — These  instru- 
ments should  be  soft  and  flexible,  with  smooth  and  highly 
polished  surfaces.    They  can  be  boiled  in  plain  water  for  a 


190  URETHRAL  INSTRUMENTS 

tVw  iiumieiits,  and  tlu'ii  })lacc(l  in  cold  Uoric  acid  s(tluti()ii. 
When  not  in  use  tliey  should  l)c  laid  away  straiulit,  and 
separate  from  each  other.  Before  usint;;  these  instruments 
we  should  always  test  their  strength,  as  they  deteriorate 
with  age,  and  may  become  so  weakened  as  to  break  ofl^' 
in  the  canal  and  slij)  into  the  bladder  (see  Fi^.  !)1 ). 

Whalebone  Filiforms. — Filiforms  must  be  kept  straight,  as 
coiling  or  bending  roughens  and  si)lits  their  surface,  thus 
rendering  them  unfit  for  use.  It  is  well  to  keep  tliein  in 
tightly  covered  metal  cases,  as  they  are  liable  to  be  attacked 
by  a  parasite,  which  renders  them  brittle  and  useless.  They 
should  be  washed  in  soap  and  cold  water,  dipped  in  alcohol, 
and  dried  on  sterile  gauze,  after  wliicli  they  can  be  placed 
in  cold  sterile  water  or  boric  acid  solution.  All  this  should 
be  done  only  a  few  minutes  before  they  are  to  be  used, 
as  long  immersion  in  watery  solutions  renders  them  too 
soft  and  pliable  to  pass  through  tight  strictures. 

Urethrotomes. — These  instruments  are  difficult  to  clean, 
and  tluTcfore  require  a  thorough  and  careful  scrubbing  with 
a  stiff  brush  and  plent\'  of  soap  and  hot  water,  especially  in 
their  grooved  and  jointed  j)ortions.  They  are  then  dried  with 
absorbent  gauze,  boiled  for  a  few  minutes  in  2  per  cent, 
carbonate  of  soda  solution  to  prevent  rusting,  or  flamed 
with  alcohol.  The  blades  should  not  be  boiled  or  flamed, 
even  for  a  short  time,  as  it  destroys  their  keen  edge;  they 
are,  therefore,  first  washed  in  soap  and  hot  water,  wij)ed 
with  sterile  gauze,  and  then  laid  in  alcohol,  from  which 
they  are  taken  for  use. 

Lithotrites. — These  instruments  are  taken  a])art,  and 
sterilized  in  the  same  manner  as  just  described  for  the 
urethrotome.  The  handle  of  the  Bigelow  instrument  must 
not  be  boilcfl. 


SOFT-RUBBER  CATII f'JT/'JUS  191 

Silver  catheters  with  tlicir  ohtiiriitors  or  st\  lets  jin-  \v;isli(;<l 
with  soai)  Hiul  hot  water,  and  their  interior  iiijeeted  first 
with  hot  soaj)sti(ls  and  then  with  alcohol;  they  may  then 
'  l)e  boiled  or  flamed  oi\  with  alcohol.  The  tip  beyond  the 
eye  should  l)e  made  solid,  so  as  to  i)revent  any  t'onii  of  dirt 
or  lul)riciuit  from  collecting  there. 

Litholapaxy  Tubes. — The  techni(;  for  sterilizing  these 
instruments,  together  with  their  obturators  or  stylets,  is 
exactly  the  same  as  that  just  described  for  the  ordinary 
silver  catheter. 

Tunnelled  Catheters. — These  instruments  are  cleaned  in  the 
same  manner  as  the  ordinary  silver  catheters,  great  care 
being  taken  to  see  that  the  tunnelled  portion  and  groove  is 
thoroughly  cleaned,  by  scrubbing  with  a  stiff  brush,  and 
plenty  of  hot  soapsuds,  before  boiling  or  flaming. 

Woven  Catheters. — These  instruments  are  covered  witli 
gum,  varnish,  or  shellac,  which  gives  them  a  smooth  and 
highly  polished  but  very  delicate  surface,  which  should 
always  be  intact  when  used.  These  catheters  are  so  con- 
structed that  they  can  be  boiled  for  a  few  minutes  in  plain 
water,  after  which  they  may  be  dipped  in  cold  sterile  water 
or  boric  acid  solution  to  restore  their  rigidity,  if  so  desired. 
They  should  be  laid  away  straight  and  not  in  contact  with 
each  other. 

Soft-rubber  Catheters. — These  are  the  catheters  of  choice 
and  should,  if  possible,  be  used  in  preference  to  either  wo^•en 
silk  or  silver  instruments  in  all  cases.  The  surgeon  should 
always  buy  the  highest  grade  of  these  instruments,  as  the 
inferior  ones  have  a  rough,  irritating  surface,  poorly  con- 
structed eye,  and  lose  their  elasticity  in  a  short  time.  The 
eye  should  be  placed  as  near  the  tip  of  the  instrument  as  it 
possibly  can  be,  or  the  tip  made  solid,  thus  obviating  a 


192 


URETHRAL  INSTRUMENTS 


dangerous  lurking-place  for  lubricants  and  dirt.  Soft-ruhlxT 
instruments  should  be  washed  in  soap  and  hot  water  and 
lia\e  plent\-  of  liot  water  injected  through  them,  after  which 


Fk 


90.— End  of  soft  rubber  catheter  broken  off  in  bladder  and  passed  by 
the  urethra.     (Author's  series,  Vandcrbilt  CUnic.) 


they  arc  boiled  in  plaui  water.  The  surgeon  should  examine 
these  instruments  from  time  to  time,  as  the  rubber,  especially 
about  the  eye,  is  liable  to  become  brittle,  which  condition. 


Fig.  91. — Half  of  silk  olivary  bougie  broken  off  in  the  bladder  and  removed 
by  perineal  cystotomy.     (Author's  service,  Bellevue  Hospital.) 

if  not  noticed,  may  result  in  the  ])reaking-oflP  of  the  end 
of  the  catheter  while  in  the  bladder  (Fig.  90).  Should 
such  an  accident  occur  the  patient  must  be  notified  of  it 


cvs'i'oscori'js  193 

at  once,  iUid  llic  piece  reliioxcd,  lliroii^di  llic  o|)er;iliii^ 
cystoscope,  l>y  means  of  tlu;  author's  tirctliral  forceps  (V'\i^. 
92);  or,  this  failing,  through  a  small  jx-rincal  or  sui)rapuhic 
cystotomy  incision.  They  should  l)e  laid  away  straight 
and  not  in  contact  with  each  other. 


'JgffLU  A  M^^lUli{W^^^^^  Na«» 


"Fig.  92. — Author's  urethnil  forceps. 

During  the  heat  of  summer  soft-rubber  and  flexible  instru- 
ments, unless  in  daily  use,  should  be  lightly  dusted  with 
French  chalk  to  prevent  them  from  sticking  together,  \\hich 
destroys  their  delicate  and  highly  polished  surfaces. 

For  transportation  in  a  sterile  condition  these  and  the 
silk  catheters  can  be  placed  in  a  glass  catheter-carrier, 
(Fig.  93),  which,  together  with  the  catheters,  can  be  placed 
in  a  sterilizer  and  boiled. 


Fig.  93. — Glass  catheter-carrier. 

Syringes. — The  large  metal  and  glass  syringes,  for  bladder 
and  urethral  irrigation,  can  be  taken  apart,  washed  and 
boiled  for  a  few  moments. 

Cystoscopes-  should  be  carefully  washed  in  soap  and 
water,  and  their  irrigatmg  and  catheter  channels  injected 
13 


194  URETHRAL  INSTRUMENTS 

with  ak'oliol,  aftrr  which  llu-y  arc  rinsed  oil'  in  sterile  water, 
dried  on  sterile  gauze,  and  i)iac'ed  in  a  Sciiering  formalin 
sterilizer,  in  which  formaldehyde  gas  is  produced  from  the 
vaporization  of  ))araform  pastils.  In  phice  of  this  they  may 
he  laid  in  sohitions  of  formahn,  '2  per  cent.,  or  oxycyaiiide 
of  mercury  (1  to  oOOO)  for  ten  or  fifteen  minutes  before  use. 
In  any  case  they  are  dipped  in  a  sterile  solution  of  boric 
acid  just  before  use,  to  guard  against  irritation  of  the  mucous 
membranes  by  the  sterilizing  agent.  They  cannot  he  boiled 
on  account  of  the  cement  around  the  lenses. 

Urethral  Catheters. — These  httle  catheters  are  made  of 
woven  silk,  and  have  delicate  and  highly  polished  surfaces, 
which  must  always  be  intact.  They  are  washed  in  soap 
and  hot  water,  carefully  injected,  dried  on  sterile  gauze,  and 
then  subjected  to  formaldeliyde  gas  in  the  sterilizer  above 
mentioned,  or  boiled  for  not  more  than  two  minutes.  Just 
before  use  they  are  dipped  in  a  sterile  boric  ackl  solution. 

LUBRICANTS. 

These  substances  must  be  smooth  and  sterile,  and  ab- 
solutely non-irritating  to  the  urethral  and  bladder  mucous 
membrane. 

If  instrumentation  is  to  l)e  followed  by  urethral  or  bladder 
medication,  the  surgeon  must  use  a  lubricant  that  is  soluble 
in  water,  otherwise  the  mucous  membrane  will  l)e  covered 
with  a  non-soluble  coating,  which  prevents  the  medicated 
fluid  from  acting  upon  the  urethral  walls. 

Of  the  soluble  lubricants,  that  made  according  to  the 
following  formula  has  pro\'e<l,  in  the  anthor's  hands,  to  be 
the  most  satisfactory: 


JNHTRUMKNTA  TION  195 


I^ — M(^r(!iiry  oxyc'yiuiidc,  gr.  v 

Gum  trnniK^iinlli,  .sc^lcclcd,  3u 

Glyeu'riu,  iicul.rul,  5ij 

Di.stillcd  Wider  Sxviij 


Lubrichondrin,  which  is  a  combinntion  of  Irish  moss,  forma- 
lin, and  (.■ucalyi)tus,  is  also  a  good  lubricant  for  general 
urethral  work. 

Glycerin  is  a  fairly  good  hibriciint,  proNidcd  the  instru- 
ment be  warm,  but  on  cold  or  e\cn  cool  metal  instruments 
it  runs  together  and  does  not  give  a  smooth,  uniform  coat- 
ing; it  is  sticky,  and  to  some  mucous  membranes  extremely 
irritating. 

White  vaselin,  although  a  good  lubricant,  is  insoluble  in 
water  and  so  greasy,  and  difficult  to  wash  oflF  of  instruments, 
the  fingers,  and  genitals,  that  it  is  only  of  service  where  we 
want  a  thick,  tenacious  coating  on  instruments  and  the 
urethral  walls,  to  protect  the  mucous  membrane  from 
injury,  as  during  the.  operation  of  litholapaxy,  in  which  it  is 
the  best  lubricant  we  have  for  lithotrites  and  tubes.  It 
can  be  obtained,  sterile,  in  collapsible  tubes. 

Olive  oil,  sterilized,  is  very  useful  for  lubricating  and 
distending  the  urethra  in  cases  of  tight  stricture,  and  before 
litholapaxy  operations;  it  is  warmed  and  injected  with  an 
ordinary  hand-syringe. 

INSTRUMENTATION. 

The  following  points  in  technic  will  be  foimd  of  much 
practical  value,  and  should  be  systematically  and  carefully 
carried  out  in  all  cases  of  urethral  and  bladder  exploration, 
examination,  and  treatment. 

For  all  cases  the  examiner's  hands  and  nails  should  be 


196  UBETHRAL  INSTRUMENTS 

cleansed  and  prt'i)art'd  as  for  gonoral  ()i)orati\i'  work,  sterile 
gloves  being  worn  if  so  desired. 

In  all  cases  the  ])enis,  ])r('])utial  cavity,  and  entire  glans 
are  washed  off  with  1  to  1000  bichloride  of  mercury  solution, 
after  which  they  are  dried  w^ith  sterile  gauze. 

The  patient  should  always  pass  his  urine  just  before 
urethral  or  bladder  cxj)loration  or  treatment,  in  order  to 
free  the  canal  of  any  accuimilated  secretion. 

Whenever  possible  the  patient  should  be  given  urotropin, 
in  full  doses,  for  twelve  to  twenty-four  hours  before  instru- 
mentation, and  for  a  day  or  two  after. 

Urethral  irrigations  before  instrumentation  should  only 
be  employed  when  the  urethra  is  filled  with  secretion  that 
cannot  be  flushed  out  by  the  urine,  on  account  of  the  trau- 
matism and  irritation  that  even  they  are  liable  to  occasion, 
and  also  the  fact  that  fluid  thrown  into  the  anterior  urethra 
by  catheter  or  irrigator  does  not  distend  the  canal  sufficiently 
to  efface  all  of  its  folds,  especially  in  the  bulbous  portion, 
and  therefore  cannot  even  cleanse  it  thoroughly.  ^Varm 
sterile  salt  or  l)oric  acid  solution  should  be  used  for  these 
irrigations  in  preference  to  solutions  of  bichloride  of  mercury, 
oxycyanide  of  mercury,  nitrate  of  silver,  or  i)ermanganate 
of  potash,  as  any  of  the  latter,  if  used  in  sufficient  strength 
to  be  of  real  germicidal  value,  set  up  more  or  less  urethral 
congestion  and  irritation,  which  condition  is  just  what  we 
should  avoid  and  guard  against  in  these  cases. 

Be  sure  that  the  patient  lies  squarely  and  comfortably 
on  his  back,  with  head  and  shoulders  elevated  and  muscles 
relaxed. 

Surround  the  penis  with  sterile  towels  or  sheets  to  prevent 
instruments  from  being  contaminated  by  contact  witli  the 
patient's  body  or  clothing. 


INSTUIJMENTA  TION  ]  97 

Solid  or  rigid  iiistruiiicnts  must  ii('V(;r  Ik;  used,  vvlicn 
soft-ruhhcr  ones  (;aii  })c  employed,  on  HC(-oiiiit  of  llie  Iriiiima- 
tism  that  may  be  occasioned  by  the  former. 

Perfect  instruments,  cleaned,  \v;iriiicd,  ;md  lubricated  as 
above  described,  should  be  j)assed  .vo  gently,  .sloivly,  and 
skUfulhj  through  the  urethra  that  they  do  not  cause  the 
slightest  contusion  or  abrasion  of  this  delicate,  highl\- 
vascular,  and  sensitive  mucous  membrane,  which,  when 
the  seat  of  traumatism,  is  so  liable  to  give  rise  to  alarming 
and  even  fatal  conditions. 


CHAPTER   XVII  I. 

fX)MM()N  AFFKCTIOXS  OF  THE  (iLAXS  AND 
VliEVVCV.. 

It  is  not  tlu'  aim,  in  this  (•lia])t(.'r,  to  tiitcr  into  a  discus- 
sion of  all  the  conditions  which  may  he  fonnd  all'ecting  the 
glans  penis  and  prepuce.  We  shall  only  take  uj)  here 
three  of  the  most  common  diseased  conditions  met  with  in 
that  region:  herpes  progenitalis,  congenital  phimosis  and 
vegetations.  Gonorrheal  phimosis,  parajihimosis,  and  balan- 
itis have  already  been  described  among  the  com])lications 
of  acute  gonorrhea,  and  the  reader  is  therefore  referred  to 
tliat  chai)ter  for  a  discussion  of  them. 

HERPES  PROGENITALIS. 

Herpes  progenitalis  is  an  inflammatory  affection  of  \arying 
intensity,  which  attacks  the  mucous  membrane  and  integu- 
ment of  the  external  genital  organs. 

The  vesicles  are  usually  found  at  the  meatus,  on  the  glans, 
in  the  sulcus  behind  the  corona,  or  on  the  inner  surface  or 
free  border  of  the  prepuce,  and  more  rarely  on  the  integu- 
ment of  the  prepuce,  penis,  or  even  pubic  region. 

It  usually  occurs  in  young  adults,  and  is  very  ])rone  to 
relapse  at  irregular  intervals. 

The  affection  consists  of  one  or  several  vesicles,  either 
grouped  together  or  .scattered  irregularly  oxer  the  i)art.  At 
first  their  content  is  clear  and  serous,  but  it  soon  becomes 


U  Eli.l'K,'^   I'WXJKNl  TA  LIH  1  0(j 

tur})i(l,  and  cvciitiuilly  dries  iij)  into  u  crust;  or  tlu;  vcsirlc 
ruptures,  Iciiviii^  a  su|)<TficiaIly  ulcerated  surfa{;e  correspond- 
ing to  the  size  of  the  original  lesion. 

If  the  little  ulcer  is  kept  clean  it  heals  (juite  rapidly  and 
without  any  coin])lications,  hut  if  from  neglect  or  iinprop(,'r 
treatment  it  l)ecomes  infected  or  irritated,  then  the  glands 
in  the  groin  hcconic  enlarged  and  painful,  and  in  some  cases 
go  on  to  sui)i)uration  and  abscess-formation. 

Prior  to  and  during  the  development  of  the  xesicles  there 
is  more  or  less  local  pain,  burning,  smarting,  or  itching  in 
the  parts,  which  when  examined  are  seen  to  be  inflamed 
and  congested,  and  the  seat  of  one  or  more  vesicles,  which 
in  a  short  time  rupture  or  dry  up  and  become  encrusted. 

As  a  general  rule,  herpes  progenitalis  occurs  most  fre- 
quently in  neurasthenic  subjects,  and  also  in  those  with 
strong  sexual  instincts.  Anything  causing  local  congestion, 
irritation,  or  inflammation  favors  its  development,  as 
balanitis,  from  disease  or  uncleanliness;  phimosis,  either  con- 
genital or  acquired;  stricture  of  the  urethra,  and  urethral 
lesions  in  general.  Sexual  and  alcoholic  excesses,  and  also 
the  rheumatic  and  gouty  "diathesis,"  are  undoubtedly  pre- 
disposing causes  in  some  cases. 

As  a  general  rule,  the  diagnosis  is  readily  made  from  the 
acute  inflammatory  nature  of  the  lesion,  the  antecedent 
pain,  itching,  and  irritation,  and  also  the  fact  that  the 
patient  has  had  many  similar  attacks. 

There  are  some  cases,  however,  in  which  it  is  quite  diflBcult, 
at  first,  to  make  a  differential  diagnosis  between  the  chancroid, 
the  chancrous  erosion  (initial  lesion  of  syphilis),  and  simple 
herpes;  therefore  the  surgeon  should  not  attempt  to  give  a 
positive  opinion  in  these  cases  until  sufficient  time  has 
elapsed  for  the  lesion  to  assume  its  typical  characteristics. 


200       AFFECriONS  OF   THE  CLANS  AND   PREPUCE 

l\x;miiii;iti()ii  of  smears  from  tlio  lesion,  by  dark-field 
illimiiiiatlon,  will  also  greatly  assist  in  arrivinfj;  at  a  diagnosis. 

Treatment. — The  jiarts  should  be  kept  absolutely  clean  by 
frequent  immersion  and  washing  in  hot  water,  or  better 
still,  hot  ])iehloride  of  mercury  solution  (1  to  5000),  after 
which  they  are  carefully  dried,  and  then  dusted  with  boric 
acid  powder  or  aristol.  If  a  wet  dressing  is  deemed  more 
advisable,  we  may  employ  boric  acid  solution,  mild  lead- 
water,  or  a  weak  solution  of  sulpliate  of  zinc  ("red  wash"), 
renewing  the  dressing  every  few  hours. 

When,  as  a  result  of  the  above  treatment,  the  ]3arts  have 
resumed  their  normal  condition,  the  cause  of  the  trouble 
should  be  sought  and  if  possible  removed.  A  phimotic 
prepuce  should  \ye  circumcised,  the  glans  kept  clean,  strictures 
dilated  or  cut,  and  urethral  lesions  properly  treated. 

Should  the  inguinal  glands  become  painful  during  an 
attack  of  herpes,  the  patient  must  be  put  to  bed  and  the 
groin  covered  wdth  a  cold  bichloride  dressing,  which,  as  a 
rule,  is  soon  followed  by  relief.  If,  on  the  other  hand,  sup- 
puration occurs,  the  resulting  abscess  must  be  incised  and 
the  pus  evacuated,  or  the  pus  let  out  by  a  small  puncture, 
and  the  abscess  cavity  injected  with  iodoform  ointment, 
for  the  technic  of  which  the  reader  is  referred  to  the  treat- 
ment of  chancroidal  "bubo"  or  adenitis. 


VEGETATIONS. 

Vegetations,  or  as  they  are  commonly  called,  warts,  are 
either  of  the  soft  or  hard  variety,  depending  upon  their 
situation;  those  found  on  mucous  membranes  and  at 
mucocutaneous  junctions  being  soft  and  moist,  while  those 


vi<:(n<:TATi()Ns 


201 


arising  from  tlie  iiitcguinciit  jiroiiiid  llic  g('iiil;il  org;iris  ;ir(; 
luird,  dry,  and  even  corneous. 

By  some  authors  these  new  growths  ;ir(;  iiicorrcrtly  spoken 
of  as  "venereal"  warts,  a  misnomer  which  should  ii(\  cr  he 
em])loyed  when  speaking  of  them. 

Vegetations  consist  of  liyj)ertrophy  of  the  |);i|)ill;i'  of  the 
skin  or  mncous  menihrane,  witli  a  corresiM)iidin<(  \;isfiil;ir 
and  eoiniective-tissne  increase. 


Fig.  94. — Soft  vegetations  (warts).     (Author's  case.) 


Their  origin  and  growth  are  due  to  uncleanliness,  heat, 
moisture,  and  friction,  and  not,  strictly  speaking,  to  venereal 
disease  or  contact. 

Soft  warts  (Figs.  94  and  95)  usually  occur  in  young  adults, 
and  more  rarely  in  older  subjects.  They  are  situated  at 
and  within  the  meatus,  on  the  glans  penis,  in  the  coronal 
sulcus,  around  the  frenum,  and  on  the  inner  surface  of  the 
prepuce.     Unless  recognized  at  an  early  date  and  properly 


2(V2       AFFECTIOXS  OF   THE  CLANS  AND   PREPUCE 

treated,  they  iiicroaso  in  size  with  ureat  rapiditx',  imoKiiit;' 
the  surrouiidiii^  tissues,  sometimes  eoxeriiiji;  the  entire 
ijhins  and  jjrotrndinjj;  from  the  ])rei)ntial  orifice  in  a  eanli- 
fl()\ver-Hke  mass.  Si)rinii;in,n-  from  either  a  hroad  and  fhit- 
tened  or  ])e(hmeuhite(l  l)ase,  they  assume  \arious  shapes 
and  sizes,  according  to  tlie  conformation  of  tlie  surrounding 
parts  or  structures;  their  color  ^■aries  from  a  deep  red,  to  a 
])ink  or  e\"en  gra\ish  hue,  and  when  in  contact  with  each 
other  or  adjacent  ])arts,  the\'  gi\e  rise  to  a  thin  secretion 
with  penetrating  and  disagreeable  odor. 


Fi(!.  !)5. — Soft  vegetations  (warts).      (Author's  case.) 


Hard  warts  (Figs.  90  and  97)  are  usually  encountered 
in  middle-aged  and  even  old  subjects,  and  are  situatetl 
u])on  the  sheath  of  the  ])enis,  on  the  scrotum,  and  also  on 
the  integument  in  general  about  the  external  genital  organs. 
They  consist  of  small  rounded  or  pointed  masses,  of  a  dirty 
brown  or  red  color,  which  increase  in  size  and  numbers, 
but  not  as  rapidly  as  the  soft  variety,  into  which  they  may  be 
converted  if  exposed  to  moisture  and  friction  from  irritating 
discharges  and  opposing  surfaces. 


VI'X.'I'JTA  TIONS 


203 


Fully  developed  soft  vegetations  are,  as  a  rule,  so  eliaraeter- 
istie  that  they  are  readily  difl'erentiated  from  other  growths 
of  the  penis,  although  there  is  a  })ar(!  j)ossihility  of  inistakiug 
them  for  condylomata  lata,  if  a  syphilitic  history  he  given. 

In  sucli  eases  the  Wassermaini  reaction  and  examination 
of  smears  by  the  dark  field  will  Jielj)  in  their  dilferentiatifjii. 


c 

,  ^ 

1^ 

j*^.- 

^-tI^B 

Sir 

K. 

/a 

1 

^f^* 

f\m 

w 

m 

^ 

1 J 

#■ 

:  A 

IP 

*■'» 

11 

1 

m. 

M 

i 

J 

-^SBKv 

>  -'  ■"f 

Fig.  96. — Hard  vegetations  (warts).      (Author's  case.) 


As  hard  warts  are  always  prone  to  undergo  malignant 
degeneration,  the  surgeon  should  remember  this  fact, 
especially  in  middle-aged  and  elderly  men,  and  always 
have  an  immediate  microscopic  examination  made  of  the 
deeper  portion  of  the  new  growth,  which,  if  found  to  be 
malignant   in   character,   should   always  be  promptly  and 


.204      AFFECTIONS  OF  THE  GLANS  AND  PREPUCE 

radically  removed,  eithor  l)y  amputation  or  total  extirpation 
of  the  penis;  together  with,  if  indicated,  the  removal  of  the 
inguinal  lymph  ganglia. 

Treatment. — The  warts  themsehes  and  the  surrountHug 
parts  are  carefully  cleansed  and  surrounded  with  sterile 
towels,  and  then,  under  local  (cocain  or  novocain)  or 
general  anesthesia,  all  of  the  vegetations  are  thoroughly 
removed  with  curved  scissors,  close  to  the  mucous  membrane 
or  integument. 


Fig.- 97. — Hard  vegetations  (warts).     (Author's  ca.se) 


The  parts  are  then  cleansed,  lightly  wiped  with  moist 
sterile  gauze,  and  dressed  with  dry  gauze  and  an\'  good 
dusting  powder,  such  as  boric  acid  or  aristol.  If  not  too 
numerous  the  warts  can  be  fulgurated  with  the  Oudin  high- 
frequency  current. 


CIRCUMCISION  205 

ir  llic  wiirts  iirc  sitiialcd  ;il)oii1  the  meatus,  fare  imist  he 
taken  not  to  cut  its  lips,  us  healing  of  the  little  wounds  will 
bo  followed  more  or  less  by  eieatrieial  eontraetioii,  with  a 
resulting  stenosis  of  this  portion  of  the  canal. 

Warts  in  the  urethra  proper  are  best  removed  through  a 
large  endoscopic  tube,  by  fulguration  witli  the  Oudiii  high- 
frequency  spark. 

If  the  patient  has  a  long  foreskin,  circumcision  should  be 
performed  when  the  warts  are  removed,  or  at  a  later  date 
if  deemed  more  advisable. 

CONGENITAL  PHIMOSIS. 

Congenital  phimosis  is  caused  by  stich  a  degree  of  narrow- 
ing of  the  preputial  orifice  that  the  foreskin  cannot  be 
retracted  beyond  the  glans;  it  is  frequently  complicated  by 
bands  or  adhesions  running  between  the  glans  and  the 
inner  snrface  of  the  prepuce,  and  may  or  may  not  give  rise 
to  mild  or  very  severe  attacks  of  balanoposthitis,  with 
painful  and  annoying  manifestations. 

Treatment. — The  palliative  treatment  consists  in  keeping 
the  parts  as  clean  and  dry  as  possible,  but  circumcision 
should  be  strongly  advised  as  the  only  cure  for  this  condition. 

CIRCUMCISION. 

The  external  genitals  are  shaved  and  rendered  surgically 
clean  in  the  usual  manner^  the  patient  urmating  just  before 
the  operation,  which  is  done  under  general  or  local  anesthesia 
in  the  following  manner:  The  prepuce  is  dra\^^l  well  forward, 
and  a  circumcision  clamp  (Fig.  98)  applied  in  such  a  manner 
that  its  blades  are  exactly  parallel  with  the  corona  (Fig.  99) ; 


206      AFFECTIONS  OF   THE  GLANS  AND   PREPUCE 

this  u'i\"cs  tlifiii  ail  (il)li(iiic  |)((^iti(l!l,as  shown  iii  the  liiiurt.'; 
thr  foreskin  is  now  ahhitcd  with  a  pair  of  iicaxy  curxcd 
scissors  or  a  straight  knife,  eiittini;'  close  to  the  distal  siih- 


Hnmmmy"!!!! 


iir^^jiw-jii- — — 


I'r;.  'J.s.--( 'ircuiiK-isinn  chiiiii). 


of  the  ehmi]),  ^\■hi{•h  is  now  renio\'ed,  when  the  iiitei;imieiit 
retracts  to  the  coronal  sulctis  and  lca\es  the  external  or 
raw  surface  of  the  mucous  layer  of  the  pre})uce  exposed. 
The  clamp  is  now  applied  to  this  layer  and  the  cutting  done 


Fig.  99. — Clamp  applied  to  foreskin. 


in  exactly  the  same  inanner  as  above  described,  which  leaves 
the  frenum  intact  and  also  plenty  of  mucous  membrane. 
Bleeding-points  are  caught  and  ligated  with  fine  gut,  and 


cntaiiMdisioN  207 

the  wouikI  closed  with  hhick-silk  intcrnipfcd  iiliirc  plnccd 
about  ouc-qiiiirtcr  incli  Ji])iirt.  A  inoist  birhloridc  dn^ssiii^ 
is  then  ii])phed,  and  the  j)atieiit  ke])t  on  his  haek,  or  xv.vy 
quiet,  for  a  (h\.\  or  so. 

If  the  operation  is  done  under  noxoeain  or  eoejdn  anes- 
tliesia,  the  solution  (0.5  to  1  })er  cent.)  shoukl  he  injected 
hypoderiuically  between  the  two  layers  of  the  foreskin 
after  the  clainp  has  been  applied,  and  alktwcd  (i\c  to  ten 
minutes  to  act  before  cutting  is  comrneueed;  when  the 
tegumentary  layer  has  been  removed,  a  little  of  the  solution 
may  be  dropped  on  the  raw  surface  of  the  mucous  layer. 
Local  cocainization  produced  in  this  manner  renders  the 
operation  comparatively  painless.  If  the  prepuce  can  be 
retracted  it  is  well  to  do  so  and  to  wrap  the  glans  and 
retracted  prepuce  with  gauze  soaked  in  2  per  cent,  cocain 
for  a  few  minutes  before  applying  the  clamps.  Should 
retraction  be  impossible,  the  preputial  cavity  may  be  dis- 
tended with  the  solution,  injected  by  means  of  a  hand- 
syringe.  In  either  case  the  mucous  membrane  of  the  pre- 
putial cavity  is  anesthetized,  thus  adding  greatly  to  the 
patient's  comfort  during  the  rest  of  the  operation.  Patients 
must  be  told  not  to  soil  the  dressing  while  urinating. 


CHAPTER  XIX. 
THE   CHANCROID. 

The  chancroid,  or  soft  chancre  (also  called  the  simple 
and  non-infecting  chancre,  or  the  local,  contagions  nicer  of 
the  genitals),  is  an  acute  inflammatory  and  destructive  lesion, 
whose  action  is  purely  local  in  character  and  limited  to  the 
parts  upon  which  it  is  situated,  and  to  the  lymphatic  vessels 
and  glands  in  anatomical  relation  with  those  ])arts. 

Chancroidal  infection  may  be  either  direct  or  mediate. 

Direct  infection  is  caused  by  the  transferrence  of  the  secre- 
tion from  the  genitals  of  one  person  to  those  of  another 
during  coitus  or  unnatural  practises. 

]\Iediate  infection  is  that  mode  in  which  the  jjus  is  trans- 
ferred upon  any  article  to  a  healthy  individual,  the  agents 
of  transfer  being  surgical  instruments,  dressings,  towels,  or 
the  fingers.  Although  this  manner  of  chancroidal  infection 
is  quite  rare,  it  does  sometimes  occur. 

Chancroid  of  the  anus  is  occasionally  met  with,  the 
infection  being  due  to  unnatural  practises  or  to  accidental 
contamination.  The  lesion  may  also  be  accidentally  trans- 
ferred to  other  parts  of  the  body. 

The  chancroid  is  in  reality  a  form  of  infected  or  septic 
wound  or  ulcer  of  the  genitals.  It  is  caused  by  the  secretion 
of  a  chancroid,  a  chancroidal  adenitis,  or  Ij'mphangitis. 
It  may  also  originate  from  any  form  of  pus  containing 
pyogenic  microbes,  as  is  well  illustrated  in  those  cases  where 


THE  CHANCIiOIlJ  209 

men  derive  cluiiuToids  from  woiiicii,  who  on  f;ircl'iil  cxunii- 
nation  reveal  iiotliiiig  but  a  purulent  discharge,  vvliieli,  ciitcr- 
iiig  a  hair  I'olliele,  chafe,  or  ahrasion  on  the  male  genitals, 
produces  a  typical  cliiUKroid. 

Cliiiiicroids  also  originate  dc  novo  in  subjects  who  }ia\'e 
not  had  sexuid  relations  for  many  months  |)revious  to  tin; 
appearance  of  the  ulcer;  these  cases  are  sonictiincs  followed 
by  suppurative  adenitis  in  either  one  or  both  groins.  The 
infecting  agent  or  cause  of  these  chancroids  is  some  form  of 
pyogenic  organism,  which  gains  access  to  the  tissues  through 
a  ruptured  herpetic  \'esicle,  or  in  fact,  any  lesion  which 
leaves  a  raw  and  absorbing  surface.  Such  instances  are 
frequently  met  with  in  patients  with  long  foreskins  who 
suffer  from  balanitis  or  herpetic  vesicles,  which  if  kept  clean 
promptly  heal,  but  if  neglected  may  become  infected  and 
thus  converted  into  typical  chancroids,  which  are  sometimes 
complicated  by  suppurating  inguinal  adenitis. 

Ducrey  describes  a  rod-shaped  bacillus  with  rounded 
ends  which  he  always  finds  in  the  chancroidal  secretions, 
and  claims,  therefore,  that  it  is  the  specific  organism  in  all 
cases  of  chancroid.  Up  to  the  present  time,  however,  he 
has  not  made  satisfactory  and  convincing  culture  and  inocu- 
lation experiments,  and  therefore  no  absolute  conclusions 
or  assertions  in  regard  to  the  specific  nature  of  the  chancroid 
can  be  made. 

The  chancroid  has  no  fixed  period  of  incubation,  usually 
making  itself  manifest  in  a  day  or  so  after  infection,  its 
rapidity  of  development  depending  on  the  resistance  of  the 
tissues  upon  which  it  is  situated;  thus  chancroids  develop 
much  more  rapidly  on  mucous  membranes  and  raw  surfaces 
than  they  do  upon  the  integinnent.  which  offers  more 
obstruction  to  the  invasion  of  the  pyogenic  microbes. 
14 


210  THE  CHANCROID 

Tlu'  chaiKToid  usually  hi-giiis  as  a  siiuill  pustule,  the 
mucous  nicuibrane  or  iutcgunicut  surrouuding  which  is 
bright  red  in  color,  which  is  due  to  the  acute  inflammatory 
and  destructive  nature  of  the  lesion.  The  pustule  soon  rup- 
tures, leaving  a  round  or  irregular  ulcer,  with  sharply  cut 
edges,  undermined  walls,  "worm-eaten,"  rough,  and  yellow 
floor,  which  gives  rise  to  a  brownish,  purulent,  and  auto- 
inoculable  secretion.  There  is  a  varj'ing  amount  of  inflam- 
matory edema  or  thickening  of  the  tissues  around  and  beneath 
the  sore,  W'hich  shades  oft"  gradually  into  the  surrounding 
parts,  thus  dift'ering  from  the  induration  of  the  chancre 
(initial  lesion  of  syphilis),  which  is  hard,  firm,  and  sharply 
limited. 

The  duration  of  the  chancroid  varies  greatly  in  difl'erent 
cases  and  depends  upon  its  extent,  situation,  and  the  treat- 
ment employed.  Chancroids  of  the  meatus  are  usually  fol- 
lowed by  more  or  less  cicatricial  stenosis  of  the  canal  at  this 
point,  while  those  situated  on  the  free  edge  of  the  prepuce 
may  lead  to  phimosis,  from  cicatricial  contraction  of  the 
preputial  orifice. 

Chancroids  are  most  commonly  found  upon  the  genital 
organs  of  either  sex,  but  may  occur  on  the  head,  face,  and 
finger,  usually  from  auto-inoculation.  They  may  be  situated 
either  on  the  free  border  or  inner  surface  of  the  prepuce, 
upon  the  penis,  at  or  within  the  meatus,  on  the  glans,  corona 
glandis,  or  in  the  sulcus  behind  the  glans.  When  occurring 
on  the  scrotum,  pubes,  thighs,  or  anus,  they  are  ordinarily 
due  to  auto-inoculation.  As  the  result  of  unnatural  practises. 
we  sometimes  find  chancroids  situated  at  the  anus,  within 
the  rectum,  and  on  the  ])erineum. 

Varieties  of  Chancroid. — Follicular  or  Acneform  Chancroid. 
— This  form  of  chancroid  begins  in  hair  or  sebaceous  follicles, 


COMPLICATIONS  OF  CIIANCUOU)  211 

and  is  situjitcd  iit  tlic  junction  of  integument  iind  niiH-ou-, 
meinbriuie.  It  orij^iinates  as  ii,  small  j)nstnle,  vvliicli  is  soon 
eonverted  into  a  deep,  ragged  ulcer,  whose  secretion  is  very 
destruetive  in  eliaraeter. 

Ecfliyniatous  Chancroid. — The  eethymatous  ehaneroid  is 
usually  found  ui)on  those  parts  of  the  integument  of  the 
genitals  which  are  dry  and  are  not  in  contact  with  opposing 
surfaces.  It  begins  as  a  little  red  spot,  which  is  finally  con- 
verted into  a  pustule  with  an  area  of  redness  around  it;  the 
pustule  increases  in  size  and  dries  up  into  a  blackish-green 
crust,  beneath  which  is  a  typical  chancroid. 

If  phagedena  attacks  a  chancroidal  ulcer,  as  it  rarely  does 
nowadays,  the  lesion  is  then  called  a  phagedenic  chancroid. 
This  serious  complication  occurs  in  persons  who  are  insuffi- 
ciently nourished  and  alcoholic,  and  in  whom  the  original 
lesion  was  vigorously  cauterized,  and  not  kept  m  a  cleanly 
condition. 

The  infected  lesion  now  has  a  foul,  purulent  secretion, 
a  sloughing  and  gangrenous  floor,  and  is  surrounded  by 
edematous  tissues,  which  are  purplish-red  in  color.  It  de- 
stroys the  soft  parts  by  extending  both  in  depth  and  at  its 
periphery. 

When  a  chancroid  becomes  really  phagedenic,  the  bearer 
has  a  brisk  rise  of  temperature,  sometimes  to  105°  F.,  with 
a  corresponding  pulse  increase,  chilly  sensations,  or  even 
well-marked  chills,  which  are  followed  by  sweating  and  a 
feeling  of  general  malaise  and  discomfort,  with  loss  of  appe- 
tite and  strength;  the  aboA'e  conditions  being  due  to  the 
absorption  of  septic  material  from  the  lesion. 

Complications  of  Chancroid. — Lymphangitis. — In  chancroid 
of  the  penis  or  prepuce  the  lymphatic  vessels  may  become 
enlarged,  hot,  red  in  color,  and  very  painful  from  absorp- 


212  THE  CHANCROID 

tioii  of  the  fliaiRToidal  secretions.  This  iiinainination  may 
either  subside  or  go  on  to  suppuration,  with  the  fornuitioii 
of  abscesses  and  chanfroichil  ukrrs  along  the  course  of  the 
lymphatic  vessels. 

Adeiiitis. — ('hancroithil  a(h'nitis  is  caused  by  the  passage 
of  septic  material  from  the  sore  to  the  glands  in  the  groin, 
by  means  of  the  lymphatic  vessels  of  the  penis. 

The  glands  in  either  one  or  both  groins  become  enlarged, 
matted  together,  and  very  painful,  while  at  the  same  time 
the  skin  over  them  assumes  a  red  and  brawny  appearance. 
Supj)uration  of  the  glandular  mass  soon  begins  and  con\erts 
it  into  a  large  abscess  ca^'ity,  which,  if  not  incised,  ruptures 
spontaneously,  leaving  a  deep,  sloughing  pocket,  with  under- 
mined and  broken-down  edges,  thus  constituting  a  typical 
chancroidal  "bubo." 

Different  Diagnosis. — The  chancroid  may  be  mistaken  for 
many  lesions  occurring  on  the  penis,  the  most  i)rominent 
among  them  being  the  hard  chancre  (initial  lesion  of  syj)hilis), 
ruptured  herpetic  vesicles,  abrasions,  chafes,  fissures,  and 
exulcerated  balanitis. 

The  hard  chancre  has  a  definite  period  of  incubation, 
usually  from  two  to  three  weeks,  and  becomes  typically 
indurated,  as  do  the  glands  in  anatomical  relation  with  it; 
its  secretion  is  serous,  and  its  fioor  smooth,  red,  and  shining 
in  appearance. 

Herpetic  vesicles  coalesce,  and  are  not,  as  a  rule,  so  deeply 
ulcerated  as  chancroids,  unless  they  become  infected.  The 
previous  history  of  the  formation  of  the  vesicles  associated 
with  local  pain  and  itching  is  of  great  aid  in  making  a  fliagnosis. 

In  exulcerated  balanitis  the  lesion  is  large  and  sn|)erficial, 
with  smooth  floor,  and  no  undermining  of  the  edges,  as 
occurs  in  chancroid. 


TREATMENT  OF  ('II A  SCIiOl  I)  AND  rOMPLK'ATfONS    213 

Ahnisioiis,  cliiilVs,  iind  fissures,  unless  iileerjit.ed,  ;ir(; 
readily  recogiiizt^d,  as  uikIct  appropriate  treatment  tliey  lieal 
rapidly,  and  leave  no  tliiekeiiin*^  of  the  tissues  u])(m  ^vllielI 
they  were  situated. 

In  diaii;nosin<;'  any  lesion  of  the  ])enis  the  physieian  nnist 
always  use  the  <i;reatest  eare  and  preeaution  before  fi;iving  a 
positive  opinion,  as  in  many  eases  it  takes  several  days  for 
the  lesion  to  assume  its  typical  appearance.  In  the  mean- 
time these  patients  are  treated  locally  by  bland  a|)i>lifa- 
tions  and  told  to  refrain  from  sexual  relations. 

The  examination  of  smears  from  the  lesion,  by  means 
of  the  dark-field  microscope,  will  also  greatly  assist  in  the 
diagnosis. 

In  connection  with  this  it  must  not  be  forgotten  that  at 
the  time  the  chancroidal  inoculation  takes  place  there 
may  also  occur  infection  with  the  spirochetse  of  syphilis. 
In  such  a  case  the  ulcer  may  appear  to  be  a  simple  chan- 
croid, at  first,  only  to  develop  later  into  the  initial  lesion  of 
syphilis,  after  the  typical  longer  incubation  period  of  the 
latter  has  passed.  Under  these  circumstances,  the  lesion  is 
spoken  of  as  a  "mixed  sore." 

Prognosis. — The  prognosis  of  chancroid  is  always  favorable, 
provided  the  sore  can  be  kept  clean,  separated  from  opposing 
surfaces,  and  the  parts  put  at  rest.  Chancroids  of  the  meatus 
or  urethra,  and  those  complicated  by  a  long,  tight  prepuce, 
are  more  difficult  to  keep  clean,  and  therefore  the  prog- 
nosis as  to  a  speedy  cure  is  not  so  favorable  as  when  the  sore 
is  more  readily  accessible. 

Treatment  of  the  Chancroid  and  its  Complications. —  The 
Chancroid. — General ■  Treatment. — Patients  suffering  from 
chancroid  must  be  kept  as  quiet  as  possible,  and  told  to 
abstain  from  alcohol  and  sexual  relations. 


214  THE  CHANCROID 

Tlu'  trcaliiu'iit  1)1'  tlic  loioii  (K-pciids  soincwhat  upon  its 
situation,  tlu-  important  ])oints  l)cinj;'  to  kvv\)  it  absolutely 
clean,  free  from  all  irritation,  sei)arat('(l  from  hcaltliy  tissues, 
and  never  to  cauterize  it. 

The  ulcer  and  surrounding  parts  should  Ix-  thoroughly 
irrigated  or  washed  in  h(^t  bichloride  of  mercury  solution 
(1  to  .3(100),  morning  and  evening,  or  more  frequently  if 
possible,  and  dried,  the  lesion  itself  being  kept  coN-ered  with 
wet  dressings  of  zinc  sulphate,  lead  subacetate,  aluminum 
acetate,  or  bichloride  of  mercury  solution  (1  to  3000  to  1 
to  5000),  which  shoukl  be  renewed  every  few  hours. 

All  the  dressings  used  upon  or  about  the  sore  must  l)e 
destroyed  as  soon  as  removed,  and  the  patient  told  to  wash 
his  hands,  ^■ery  carefully,  immediately  after  the  dressing  is 
completed. 

In  all  cases  cauterization  is  absolutely  unnecessary  and 
e\en   harmful,   and   should   therefore  ne\er  be   employed. 

If,  however,  in  spite  of  cleanliness  and  proper  local  treat- 
ment, the  lesion  extends  and  threatens  the  destruction  of 
the  surrounding  parts,  as  it  very  rarely,  if  ever,  does,  then 
we  may  be  compelled  to  resort  to  applications  of  tincture  of 
iodin  by  means  of  swabs  of  absorbent  cotton  wrapped  on 
a  small  wooden  appUcator.  Care  must  be  taken  to  apply 
the  tincture  of  iodin  to  the  floor  of  the  lesion  and  its  under- 
mined walls  and  edges,  but  not  to  the  surrounding  healthy 
tissues.  A  cold  bichloride  dressing  is  then  applied  to  allay 
the  pain  and  inflammation  following  this  application,  and  the 
patient  told  to  keep  very  quiet. 

Chancroids  of  the  fossa  navicularis  require  the  following 
special  treatment:  The  patient  having  urinated,  the  prepuce 
is  retracted  and  the  parts  washed  with  l)ichloride  solution. 
A  small   soft-rubber  catheter,  properly  lubricated,  is  then 


TREA  TMKNT  OF  ClfA  NCIIOI I)  A  Nl)  COM I'LICA  T/O.S'S     '1 1  .'> 

piissccl  ii|)  llic  iircllirii  hcyoiid  llic  lesions,  and  hot,  horic 
acid  solution  is  injected  l)y  means  of  a  large  hand-syringe  or 
irrigator.  In  this  inainier  the  canal  is  washed  out  from 
behind  forward,  the  solution  esca})ing  at  the;  meatus.  This 
procedure  should  be  repeated  three  or  four  tiin(!S  a  day. 
Should  the  lesion  prove  resistant,  we  may  supi)lement  these 
irrigations  by  the  application  of  solutions  of  zinc  sulf)liate 
or  alum  (1  or  2  per  cent.),  or  of  tincture  of  iodin,  ajjjilicd 
through  an  endoscopic  tube,  by  means  of  absorbent  cotton 
swabs. 


Fig.  100. — Phimosis  scissors.     (Taylor.) 


Chancroids  situated  beneath  a  long,  tight  prepuce,  which 
cannot  be  retracted,  require  frequent  subpreputial  injections 
or  irrigations  of  hot  bichloride  of  mercury  solution.  A 
better  plan,  however,  is  to  make  two  lateral  incisions  through 
the  foreskin  and  expose  the  parts  for  inspection  and  local 
treatment,  thus  preventing  sloughing,  with  more  or  less 
destruction  of  the  glans  and  surrounding  tissues.  This 
operation  is  performed  in  the  following  manner: 

The  patient  having  been  anesthetized,  the  parts  are 
shaved  and  rendered  surgically  clean  in  the  usual  manner, 
and  with  heavy  phimosis  scissors  (Fig.  100)  or  a  scalpel  and 
grooved  director,  a  lateral  cut  is  made  through  each  side  of 


210 


THIi   CHANCROID 


tlu'  j)i-('i)iicc  tVoin  its  free  cdu'c,  well  down  into  tlic  coronal 
sulcus,  tlius  t'oi'minu'  an  ui)pc'r  and  lower  (lap,  wliicli,  when 
retracted,  exjxjse  tJie  entire  glans  j)enis  and  tJie  inner  surface 
of  the  foreskin  (Viii;.  101),  wliich  is  not  tlie  case  when  tlie 
dorsal   incision   is   made.     The  parts  are  kept  constantly 


Fici.  101. — Lateral  infisioiis.      (Papier  mar-hc  model  by  Dr.  Roynold.s.) 


irrifjated  durinii;  the  operation  witli  hot  bichloride  solution. 
The  chancroids  are  then  treated  as  already  described,  and 
the  raw  edges  of  the  wounds  protected  from  infection  by 
frequent  dressings  and  irrigations  with  very  hot  bichloride 
solution.     The  liemorrhage,  which  is  quite  free,  is  readily 


ADh'NfT/S  217 

controlled  l)y  llu-  pccssiirc  of  the  (li-cs,siii<i.  \'>\  a  simple 
j)lii.stie  o|)era,tioii  the  flaps  iiiay  l)C  triiiiiiied  oil',  if  iie(;(;.ssary, 
and  the  edges  sutured,  at  a  later  date,  vvJieii  tJic  infection  has 
subsided  and  tJie  wounds  have  healed. 

Adenitis. — If  during  the  course  of  chancroids  the  inguinal 
glands  become  enlarged  and  painful,  the  patient  should  be 
kept  very  quiet  or  put  to  bed.  A  cold,  wet  bichloride  or 
alummum  acetate  dressing  is  often  followed  by  favorable 
results  in  this  condition.  Dressings  of  20  per  cent,  ichthyol 
or  of  compound  iodin  ointment  are  also  useful  in  some  cases. 
If  in  spite  of  the  treatment  above  given  the  glands  fuse 
together,  break  down,  and  suppurate,  thus  forming  an 
abscess,  they  must  be  promptly  treated  either  by  evacuation 
of  the  pus  and  injection  of  iodoform  ointment,  or  by  free 
incision  with  removal  of  the  infected  glands. 

First  Method. — This  method,  which  was  advocated  by 
Helm,  and  which  I  have  somewhat  modified,  should  be  tried 
in  all  suitable  cases  of  suppurative  adenitis,  as  it  leaves  no 
scar,  nor  is  it  necessary  for  the  patient  to  take  an  anesthetic, 
remain  in  bed,  or  be  subjected  to  a  more  or  less  painful  and 
tedious  convalescence.  The  steps  in  the  procedure  are  as 
follows : 

1.  The  operative  field  and  genitals  are  shaved  and  rendered 
surgically  clean  in  the  usual  manner  and  the  penis  bandaged 
with  sterile  gauze. 

2.  A  few  drops  of  a  1  per  cent,  solution  of  cocain  or 
novocain  are  injected  beneath  the  skin  where  the  puncture 
is  to  be  made. 

3.  A  straight,  sharp-pointed  bistoury  is  then  thrust  well 
into  the  most  prominent  part  of  the  tumor  until  pus  flows. 

4.  All  of  the  pus  is  forced  out  through  this  opening  by 
firm  but  gentle  pressure,  as  this  procedure  is,  as  a  rule,  painful. 


218  THE  CHANCROID 

5.  Tlie  abscess  Ciuity  is  irrigated  \vitli  peroxide  of  Jiydro- 
gen  until  the  return  is  practically  clear. 

6.  It  is  then  irrigated  with  a  1  to  5000  biclih^ride  of  mercury 
or  salt  solution,  all  of  which  is  carefully  squeezed  out. 

7.  The  now  thoroughly  cleansed  abscess  cavity  is  com- 
pletely filled,  but  not  painfullj'^  distended,  with  10  per  cent, 
iodoform  ointment,  by  means  of  an  ordinary  ccMiical  glass 
syringe  pre\iously  warmed  in  hot  water. 

8.  A  cold,  wet  bichloride  dressing  is  applied  with  a  fairly 
firm  spica  bandage,  the  cold  congealing  the  ointment  at  the 
wound  and  thus  preventing  its  escape  into  the  dressing. 

The  patient  should  be  kept  verj^  quiet  for  the  first 
twenty-four  to  forty-eight  hours,  rest  in  bed  being  prefer- 
able, althougli  not  absolutely  necessary. 

The  dressing  is  remo^•ed  at  the  end  of  the  third  or  fourth 
day  and  the  parts  examined.  If  i)us  has  reaccumulated,  a 
second  injection  may  be  made.  If,  on  the  other  hand,  all 
looks  well,  the  first  dressing  is  replaced  by  a  gauze  pad  and 
spica  bandage,  and  the  patient  told  to  report  in  two  or  three 
days  for  examination. 

In  order  to  secure  the  most  favorable  results  from  this 
method,  it  should  only  be  employed  when  the  glands  are 
thoroughly  broken  down,  fluctuation  well  marked,  and  the 
integument  thinned  over  the  most  prominent  part  of  the 
tumor  so  that  the  iodoform  may  come  in  direct  contact  with 
all  of  the  infected  tissues.  If,  after  one,  two,  or  even  three 
injections,  this  method  fails  to  produce  the  desired  result,  an 
incision  may  then  be  made  and  the  contents  of  the  abscess 
removed,  the  previous  treatment  not  having  interfered  in 
any  way  with  this  operation. 

Second  Method. — The  patient  having  been  anesthetized  and 
prepared  as  usual,  a  long  incision  is  then  made  over  tlie  most 


ADEN  IT  I H 


210 


prominent  ]);iH.  of  \\\v.  iiiiiss  jiihI  |);ii-iillcl  witli  tlic  iiiKninul 
fold,  tlius  exposing  tlic  hrokcii-dovvii,  suppunitiiig,  and 
infected  glands,  wliieli  mnst  l)e  tJiorouglily  removed,  great 
care  being  exercised  not  to  wound  the  femoral  vessels  or 
their  branches.  Bleeding-points  are  caught  and  ligated, 
and  the  abscess  cavity  thoroughly  irrigated  with  ])cn)\idc  f)f 


Fig.  102. — Chronic  edema  of  penis  and  scrotum  follo^dng  complete  extir- 
pation of  the  right  inguinal  glands.     (Author's  case.) 


hydrogen  and  hot  bichloride  of  mercury  solution  (1  to  2000). 
The  now  clean  and  dry  wound  is  packed  with  moist  sterile 
gauze,  over  which  is  placed  the  usual  sterilized  gauze  and 
cotton  dressing,  which  is  held  in  position  by  a  firm  spica 
bandage.  No  attempt  at  suturing  should  be  made  in  these 
cases  on  account  of  the  inflamed  and  infiltrated  condition 


220  TIJE  CHANCROID 

of  the  tissues,  wliicli,  if  left  fi-cr  tn  dfalii,  will,  under  tlio 
jji'oper  treatment,  granulate  (piite  I'apidly  IVom  tlie  hottoni, 
and  not  be  followed  by  sinuses,  as  is  so  freciuently  the  ease 
wlien  the  wound  has  been  sutured,  and  primary  union 
obtained  at  only  a  few  points. 

In  severe  cases,  where  the  pus  has  burrowed  downward 
to  the  thigh  and  up  on  the  abdominal  wall,  it  is  well  to 
eombine  a  vertical  with  the  transverse  incision  for  purpose 
of  better  and  freer  drainage. 

It  must  not  be  forgotten  that  the  too  radical  removal  of 
the  inguinal  lymphatics  is  sometimes  followed  by  edema  of 
the  lower  extremity,  or  the  penis  and  scrotum,  which  is 
severe  in  character,  chronic  in  course,  and  very  rebellious 
to  treatment  (Fig.  102). 


CHArTKR  XX. 
SYPHILIS. 

Syphilis  is  a  cJironic,  infectious,  and  constitutional 
disease,  always  beginning  in  a  local  lesion  called  the  initial 
lesion  or  chancre,  which,  in  acquired  syphilis,  invari- 
ably marks  the  point  of  entry  of  the  syphilitic  \irus  (or 
spirocheta).  Entering  the  system  by  means  of  the  blood- 
vessels, lymphatics,  and  perivascular  lymph  spaces,  it 
attacks  primarily  the  connective  tissue,  and  in  its  course 
may  affect  every  tissue  and  organ  in  the  body. 

The  disease  is  characterized  by  an  increase  of  the  con- 
nective-tissue cells  and  by  the  development  of  a  new  tissue, 
called  granulation  or  gummatous  tissue,  composed  of  small 
round  cells  resembling  somewhat  white  blood  corpuscles, 
in  which  are  found  the  spirochete  in  varying  numbers. 

Etiology. — The  microorganism  which  is  the  cause  of  the 
disease  is  a  flagellate  protozoon  discovered  in  1905  by 
Schaudinn,  and  named  by  him  the  Spirocheta  pallida 
(Treponema  pallidum)  (Fig.  103).  It  is  found  in  all  the 
lesions  of  the  disease,  including  general  paresis  and  tabes 
dorsalis,  though  its  detection  in  these  last  "is  so  very  difficult 
that  it  has  only  recently  been  accomplished.  The  spirocheta 
varies  from  4  to  14  mmm.  in  length,  with  a  breadth  of  from 
^  to  I  mmm.  The  number  of  turns  of  the  spiral  is  from  8  to 
26,  the  turns  being  narrow  and  corkscrew-like.  The  organ- 
isms mav  be  found  in  smears  stained  hv  Giemsa's  stain;  the 


222 


SYPHILIS 


examination  of  the  infected  secretion  by  dark-fic'ld  illumina- 
tion (the  best  method),  and  by  flooding  the  smear  with 
Cliincse  ink,  when  they  will  appear  as  bright  spirals  shining 
against  a  dark  background,  provided  too  much  ink  is  not 


Spirochpta 
refringens. 


Spiroclu'ta 
pallida. 


Fig.  103. — Spircjclicta  pallichi  and  Spiroclu'tii  rofriii^cii.s. 


used.  The  smears  should  not  be  made  from  the  surface 
secretion  of  the  lesion  but  from  the  exudation  obtained  by 
gently  scraping  the  ulcer  until  a  colorless  serum  exudes. 
For  further  details  the  reader  is  referred  to  the  standard 
works  on  bacteriology. 


ET1()L0<;y  223 

There  are  two  forms  of  sypliilis:  the  acquircfl  form  ;ind 
the  hereditary  form;  both  are  due  to  tl)e  saiin;  orgjuiisrn, 
but  differ  in  tlieir  course  and  manifestations. 

Acquired  syphilis  is  communicated  by  a  syphiHtic  pcrscm 
to  one  free  from  tlie  disease,  tlie  point  of  inoculation  being 
always  marked  by  the  initial  lesion  or  chancre. 

Hereditary  syphilis  is  transmitted  in  utero  from  citiicr 
one  or  both  parents,  and  in  this  form  there  is  no  initial 
lesion;  the  onset  of  the  disease  being  marked  by  general 
manifestations. 

As  a  general  rule,  syphilis  occurs  but  once  in  the  same 
individual,  although  reinfection  may  take  place  both  in  the 
acquired  and  the  hereditary  forms,  as  a  number  of  cases 
have  been  reported  in  which  reinfection  has  occurred  after 
treatment,  with  mercury  and  salvarsan,  of  the  initial  attack. 

The  course  of  syphilis  is  best  divided  into  three  stages: 
the  primary,  the  secondary,  and  the  tertiary;  but  it  must 
not  be  forgotten  that  in  a  certain  number  of  cases  tertiary 
lesions  may  occur  in  the  secondary  stage,  or  vice  versa,  or 
that  lesions  of  these  different  stages  may  be  present  at  the 
same  time,  thus  showing  that  the  disease  does  not  invariably 
follow  these  sharply  defined  periods. 

Primary  Stage. — The  primary  stage  of  syphilis  consists  of 
two  periods  of  incubation.  The  first  period  of  incubation 
exists  from  the  time  of  infection  to  the  appearance  of  the 
initial  lesion,  and,  as  a  rule,  lasts  from  fourteen  to  twenty- 
one  days;  but  may  be  as  short  as  ten  or  as  long  as  seventy 
days.  This  is  immediately  followed  by  the  second  period 
of  incubation,  which  dates  from  the  formation  of  the  initial 
lesion  to  the  development  of  constitutional  manifestations, 
and  usually  occupies  forty  to  forty-five  days,  but  may  be 
prolonged  to  sixty,  seventy,  or  even  ninety  days. 


224  SYPHILIS 

These  two  periods  of  incubation  make  up  the  primary 
stage  of  SNpliiHs,  the  duration  of  wliich  is  from  fifty  to 
eighty  days. 

The  lesions  of  tlie  primary  sta<i;e  are  tlie  initial  lesion,  or 
chancre,  and  the  glandular  and  lymphatic  indurations  in 
anatomical  relation  with  it,  these  glands  and  vessels  becom- 
ing intlurated  from  about  the  se\'enth  to  the  tenth  or 
fourteenth  day. 

Secondary  Stage. — The  secondary  stage  of  syphilis,  or  the 
stage  of  constitutionl  manifestations,  now  begins,  and  is 
characterized  by  superficial  lesions  of  the  skin  and  mucous 
membranes,  as  well  as  their  appendages,  and  by  affections 
of  the  eyes,  and  enlargement  of  the  superficial  and  dceji  lym- 
phatic ganglia  throughout  the  entire  body,  which  enlarge- 
ment usually  commences  quite  early  in  the  secondary  period 
of  incubation.  The  duration  of  this  stage  is  variable,  usually 
lasting  from  one  to  two  years,  and  de])ending  greatly  u])on 
the  treatment,  the  habits,  and  the  constitution  of  the  patient. 

Tcrilart/  Stage. — The  tertiary  stage  usually  begins  at  about 
the  end  of  the  second  year,  but  is  not  so  frequently  observed 
now  as  formerly,  owing  to  impro^'ed  methods  of  treatment. 
It  manifests  itself  by  gummatous,  tubercular,  bullous,  and 
ulcerative  lesions,  also  by  affections  of  the  ner\ous  and 
\ascular  systems,  the  viscera,  and  bones. 

Contagion. — The  secretion  of  the  initial  lesion  is  highly 
contagious.  The  secretions  of  the  secondary  lesions  (mucous 
patches,  condylomata,  etc.),  and  the  blood  and  lymph,  in  the 
secondary  stage,  are  also  contagious.  The  physiological 
secretions,  such  as  the  tears,  milk,  saliva,  and  sweat,  may 
be  considered  imiocuons,  unless  mixed  with  blood  or  secre- 
tions from  primary  and  secondary  lesions,  which  in  turn 
renderjthem  contagious.     The  semen  is  innocuous  upon  a 


I N  l<' l<:( 'Tl  ()  N  Tl') 

cutaneous  or  uuicous  surl'itcc,  \n\\.  may  trjuisniit  syj)liilis  to 
tlic  ovum.    'J'lic  urine  is  in  Jill  j)rol)al)iJit\'  also  innocuious. 

The  secretions  of  the  tertiary  lesions  are  also  (^ontaRious, 
as  the  spirochette  are  lound  in  tlicni,  ;iltlii)u;j;li  <»iily  in  -imill 
nuinlxM's  and  ])rohiil)ly  of  iniicli  diniinislied  virulence. 

Infection. — SypJiilitic  infection  may  be  either  direct  or 
mediate. 

Direct  injection  takes'  place  most  frequently  from  the 
genitals  of  one  person  to  those  of  another  durinj^  coitus, 
also  in  unnatural  sexual  practises  in  depraved  individuals. 

Mouth-to-mouth  infection,  as  in  kissing,  is  not  infrequent. 

Surgeons,  physicians,  dentists,  and  nurses  are  very  liable 
to  infection  on  the  fingers  and  hands,  and  should  therefore 
exercise  great  care  in  handling  or  operating  upon  sypliilitic 
subjects. 

Mediate  infection  is  that  form  in  which  the  sypliilitic  secre- 
tion is  deposited  upon  any  article,  and  then  transferred  from 
it  to  a  healthy  person.  The  agents  of  transfer  may  be  cigars, 
pipes,  tooth-brushes,  pencils,  chewing-gum,  handkerchiefs, 
whistles,  drinking  and  eating  utensils,  razors,  towels,  toys, 
plasters,  postage  stamps,  surgical  operations — dressings,  in- 
struments, etc.  Glass-blowers  may  be  infected,  as  a  number 
of  men  use  the  same  pipe.  Vaccinosyphilis  is  very  rarely 
encountered  at  present,  owing  to  the  substitution  of  bovine 
for  human  virus. 

When  the  disease  is  contracted  in  any  of  the  above  ways — 
that  is,  without  sexual  contact — it  is  called  si/philis  insontium, 
syphilis  of  the  innocents,  or  unmerited  syphilis.  Syphilis  is 
precisely  the  same  disease,  and  pursues  the  same  course, 
whether  derived  from  the  secretion  of  a  primary,  secondary, 
or  tertiary  lesion,  in  any  case  the  point  of  entry  of  the 
syphilitic  virus  being  marked  by  the  initial  lesion  or  chancre. 
15 


220  SYPHILIS 

Prognosis. — As  a  general  rule,  it  may  safely  be  stated 
that  patients  wlio  are  otJierwise  in  a  perfectly  healthy  con- 
dition experience  very  little  trouble  from  syphilis,  provided 
they  have  the  proper  form  of  constitutional  and  local  treat- 
ment for  a  sufficient  length  of  time,  and  live  moderate,  tem- 
perate, and  regular  lives,  according  to  the  rules  laid  down  by 
the  physician.  It  is  usually  thought  that  blondes  and  sub- 
jects with  light  complexion  and  reddish-brown  or  red  hair 
are  prone  to  suffer  more  than  those  of  dark  complexion.  The 
disease  is  apt  to  be  very  severe  in  old  age,  and  in  nervous, 
excitable,  and  neurasthenic  subjects.  Alcoholic  habits,  drug 
addictions,  and  interciu'rent  diseases,  especially  Bright's 
disease,  diabetes,  cancer,  and  tuberculosis,  render  the  prog- 
nosis much  less  fa\'orable.  Syphilis  sometimes  runs  a  very 
severe  course  in  fat  and  flabby  subjects,'  also  in  very  thin 
and  anemic  ones  with  poor  muscular  and  chest  develop- 
ment. 

A  guarded  prognosis  must  always  be  made  in  poorly  and 
insufficiently  nourished  subjects,  and  also  in  those  whose 
vitality  and  resistance  have  been  lowered  by  disease,  bad 
habits,  worry,  care,  grief,  etc. 

As  a  general  rule,  women  do  just  as  nicely  and  withstand 
the  disease  as  well  as  men,  provided  they  adhere  to  a  proper 
and  sufficient  course  of  treatment. 

There  are  undoubtedly  ^'ery  rare  instances  in  which  the 
disease  tends  to  self-limitation,  but  one  cannot  prognosticate 
with  accuracy  which  case  will  do  well  and  which  one  badly; 
the  physician  must  therefore  be  very  guarded  in  giving  his 
opinion,  always  taking  into  consideration  the  habits  and 
general  condition  and  make-up  of  his  patient,  who  should 
always  be  plainly  and  emphatically  informed  that  tlie  loyalty 
and  common-sense  with  which  he  carries  out  minutely  all 


PROCNOSIS  Til 

of  the  details  of  treatment  are  most  important  factors  in 
his  cure,  as  the  ])hysician  alone  cannot  accomplish  all. 

It  must  he  remembered  that  with  our  imj)rovefl  methods 
of  treatment  (salvarsaii  and  iieosjiKarsaii)  tJie  prognosis  is 
much  more  favorable,  in  the  vast  majority  of  cases,  than  it 
formerly  was. 


CHAPTER  XXI. 

TIIK   INITIAL  LESION. 

The  initial  lesion  of  syphilis  is  also  called  the  chancre; 
the  hard,  or  Ilunterian  chancre;  the  initial  sclerosis;  the 
primiti\e  or  initial  neoplasm  and  primary  syphilitic  ulcer. 


Fig.  104. — Chancre  of  lip.      (Author's  case.) 

It  originates  from  syphilitic  blood,  or  from  the  secretions  of 
primary,  secondary  or  tertiary  lesions,  appears  at  the  end 
of  the  first  period  of  incubation  (fourteen  to  twenty-one 
days),  and  is  always  situated  at  the  j)()int  of  entrance  of  the 
Spirocheta  ])allida. 

L'sually  there  is  but  one  initial  lesioii,  although  several 
may  be  present  at  the  same  time,  infection  lia\ing  occurred 
simultaneously  at  several  points. 


SEAT  OF  CIIANCIIK 


220 


Seat  of  Chancre.  Cliiiiicrcs  loiiml  niton  llic  ;,rcnit;il  orL^nn-. 
«'irc  CJillcd  (/rtiildl  rliaiirrr.s-;  \vJiil(;  tliosc  sitiiiit(;(l  clscw  licrc 
upon  tlic  body  arc  (Icsigiiatcd  as  e.draf/enifcil  (•hanrrcs. 


Fig.  10.5. — .Chfincrc  of  upper  lip.      (Amhui'-  case.) 

Most  frequently  the  initial  lesion  occurs  upon  the  genitals, 
but  it  may  be  situated  anywhere  upon  the  body — as  the  lips 


Fig.  106. — Chancre  of  lip.     (Author's  case.) 


(Figs.  104,  105,  and  106),  the  tongue  (Fig.  10/),  the  tonsils 
(Fig.  108),  the  eyelid  or  conjunctiva,  the  ear,  the  forehead, 


280 


THE  INITIAL  LESION 


the  face,  the  neck,  tlie  fingers,  tlie  pubes,  tlie  belly,  the 
breasts,  the  arms,  the  thighs,  the  liands,  tlic  anus,  or  witliin 
the  rectum. 


Fig.  107. — Chancre  of  tongue.     (Author's  case.) 


Fig.  lOiS. — Chancre  of  tonsil.     (Author's  case.) 


^MAT  OF  ClIANCIlE  231 

In  looking  for  the  site  of  the  initial  lesion  in  obscure  cases 
it  is  well  to  bear  in  mind  the  chnical  fact  that  the  lym- 
phatic glands  in  anatomical  relation  with  the  lesion  are 
always  the  largest  and  most  indurated. 

There  is  notln'iig  absolutely  characteristic  in  the  appear- 
ance of  the  initial  lesion  in  its  very  early  stages.  Most  com- 
monly it  begins  as  a  small  erosion  from  which  exudes  a 
variable  amount  of  serous  secretion;  but  it  may  first  appear 
as  a  small,  dry  papule,  or  closely  resemble  a  ruptured 
herpetic  vesicle,  or  as  a  small,  white,  silvery  spot,  or  purple 
necrotic  nodule.  Whatever  the  form  first  assumed,  how- 
ever, the  chancre  finally  develops  into  a  superficial  erosion, 
with  purplish  zone,  sloping  sides,  smooth,  red,  shining  floor, 
and  profuse  serous  secretion,  situated  upon  and  surrounded 
by  a  circumscribed  mass  of  induration. 

Infecting  Balanoposthitis. — This  is  a  form  under  which  the 
initial  lesion  sometimes  appears,  and  may  be  mistaken  for 
simple  balanoposthitis,  so  that  we  should  always  be  very 
guarded  in  making  a  positive  diagnosis  in  these  cases.  The 
prepuce  is  infiltrated,  its  mucous  membrane  thickened, 
purplish-red  in  color,  and  slightly  excoriated.  The  glans 
penis  may  or  may  not  be  eroded.  In  some  cases  the  indura- 
tion is  localized,  in  others  it  is  evenly  distributed,  causing 
phimosis  from  thickening  and  hardening  of  the  prepuce. 

The  induration  of  the  chancre  is  a  cartilaginous  hardness 
of  the  tissues  around  and  beneath  the  lesion,  and  is  not  really 
typical  until  about  the  seventh  or  fourteenth  day  after  the 
appearance  of  the  chancre.  It  is  due  to  a  deposit  of  granu- 
lation tissue,  which  takes  place  without  acute  inflammation, 
and  which  is  sharply  defined  at  its  circumference  from  the 
surrounding  structures.  The  amount  of  induration  varies, 
and  depends  greatly  upon  the  site  of  the  chancre ;  it  is  always 


232  THE   IMTIAL    LKSIOX 

well  niarki'd  in  the  sulcus  heliind  the  corona  glandis,  at  and 
witliin  the  meatus,  or  on  the  corona,  hut  is  ahscnt  or  very 
sliglit  indeed  t)n  the  glans  })enis  itself.  As  a  rule,  the  indura- 
tion remains  until  the  chancre  has  liealed,  although  its 
duration  is  entirely'  dependent  upon  appropriate  local  and 
constitutional  treatment. 

Parchment  induration  is  that  ^•ariety  of  induraticm  in 
which  the  deposit  is  superficial  and  confined  to  the  tissues 
directly  hcm-ath  the  lesion. 

Iicldp.s'infi  Induration. — At  any  time  during  the  course 
of  syphilis  indurated  nodules  may  ai)pear  on  the  genitals, 
usuall\'  u])on  tlie  site  of  the  original  lesion;  they  are  either 
superficial  or  deep,  and  may  be  mistaken  for  primary  lesions, 
especially  when  their  siu'faces  become  eroded  and  give  rise  to 
secretions.  These  nodules  have  been  observed  as  early  as 
the  first  and  as  late  as  the  tenth  year  of  the  disease  in 
treated  cases. 

The  secretion  of  the  chancre  is  profuse  and  serous  in  char- 
acter unless  the  sore  has  been  irritated  or  infected,  when  it  is 
rendered  purulent;  but  even  then  the  ])us  lias  a  peculiar 
watery  or  shiny  look,  due  to  the  admixture  of  scrum,  and 
this  must  always  be  taken  into  consideration  when  making 
a  diagnosis.  When  infection  of  the  lesion  does  occur  the 
differentiation  from  a  "soft"  chancre  is  often  difficult,  as 
pointed  out  before,  in  the  chapter  on  Chancroifl,  wJien 
speaking  of  the  so-called  "mixed  sore." 

TJie  duration  of  the  chancre  varies  in  different  cases  and 
depends  entirely  upon  the  treatment.  It  may  remain  until 
after  the  development  of  secondary  symptoms,  })ut  tliis 
should  never  occur  jjro\idc(l  the  lesion  has  had  i)roper 
treatment  from  its  incij)iency. 

As  a  general  rule,  the  site  of  the  initial  lesion  is  not  marked 


Tia<:ATMi<:NT  of  Tiih:  ciiANcin':  2'.'>'.\ 

by  ii  ciciitrix,  hut  hy  ;i  pnrplisJi  s|)()t,  wliicli  in  tiinc  fades  to 
wliito.  If,  Jiowevcr,  the  cliaiicre  was  infected  and  suppurat- 
ing, then  there  may  he  more  or  less  of  a  depression  or  sear 
left  as  a,  result  of  the  local  tissue  destruction. 

The  diagnosis  should  he  made  on  tJie  i)eri'><l  of  inciihatiftn, 
the  induration  about  the  ulcer,  the  smootJi,  sJiining  surface, 
with  profuse,  serous  discharge,  when  the  lesion  is  not  the 
seat  of  a  mixed  infection,  and  the  discoxcry  of  the  Spinx-heta 
pallida,  in  smears  from  tlie  ulcer,  by  dark-field  examination. 
The  Wassermann  reaction  is  also  useful,  after  the  lesion  has 
existed  for  some  time,  but  is  very  rarely  positi\e  before  tJie 
end  of  the  second  week,  and  often  remains  negative  for  a 
much  longer  period. 

Treatment  of  the  Chancre. — The  most  thorough  cauteriza- 
tion, or  even  the  complete  excision  of  the  initial  lesion,  with 
the  lymphatic  glands  and  vessels  in  anatomical  relation  with 
it,  even  if  performed  at  the  time  of  its  appearance,  is  of  no 
avail  in  aborting  syphilis,  as  the  spirocheta  travels  so  rapidly, 
by  way  of  the  bloodvessels  and  perivascular  lymph  spaces, 
that  very  distant  and  remote  parts  are  infected  by  the  time 
the  chancre  appears.  For  this  reason,  therefore,  which  has 
been  demonstrated  both  clinically  and  microscopically,  exci- 
sion and  cauterization  of  the  chancre  as  aborti\'e  measures 
should  never  be  performed. 

The  local  treatment  consists  in  scrupulous  cleanliness  of 
the  lesion  and  its  protection  from  all  sources  of  irritation  and 
infection.  The  patient  must  be  told  to  abstain  from  sexual 
relations,  and  to  exercise  the  greatest  care  and  precaution 
in  order  to  guard  against  and  pre^'ent  the  infection  of  others. 
The  lesion  should  be  washed  with  bichloride  of  mercury 
solution  (1  to  3000)  morning  and  evening,  or  oftener,  and 
covered  with  absorbent  cotton  saturated  in  this  solution; 


234  THE  INITIAL  LESION 

this  dressing  is  changed  o\  cry  few  lionrs,  tlie  soiled  one  being 
destroyed  immechately.  and  tlic  ])aticnt  told  to  wasli  liis 
hands. 

Dihite  "black  wash"  is  sometimes  very  serviceable  when 
there  is  a  tendency  to  the  formation  of  a  superficial  slough. 

Calomel,  or  equal  parts  of  calomel  and  boric  acid,  may 
also  be  used  as  a  dusting  powder.  As  a  general  rule,  how- 
ever, the  best  dressing  for  the  chancre  is  absorbent  cotton 
kept  saturated  with  bichloride  solution  and  changed  at 
frequent  intervals,  as  dusting  powders  have  a  tendency  to 
form  crusts  over  the  lesion  and  interfere  with  cleanliness  and 
healing,  and  with  proper  inspection  of  the  ulcer. 

Chancre  situated  beneath  a  long,  tight  foreskin  that  can- 
not be  retracted  (phimosis),  from  beneath  which  exudes  a 
foul,  purulent  or  seropurulent  discharge,  and  that  fails  to 
respond  promptly  to  the  general,  constitutional  treatment 
to  be  described  later,  should  always  be  exposed  by  making 
two  lateral  incisions  tlirough  the  prepuce,  for  which  operation 
the  reader  is  referred  to  the  chapter  on  Chancroid. 

When  the  chancre  is  cicatrized  the  remaining  mass  of 
induration  should  be  kept  constantly  covered  with  50  per 
cent,  mercurial  ointment,  which  in  a  short  time  will  cause 
it  to  soften  and  disappear,  leaving  a  purple  spot,  which  in 
time  fades  to  white.  The  ointment  should  be  changed 
morning  and  evening  to  prevent  its  decomposition,  with 
consequent  irritation  of  the  parts. 

Adenitis. — ^The  lymphatic  glands  in  the  immediate  neigh- 
borhood of  the  chancre  become  indurated  on  about  the 
seventh  to  the  fourteenth  day  of  its  existence;  they  are 
painless,  freely  movable  upon  and  separate  from  each  other, 
and  do  not  suppurate  unless  the  sore  has  been  infected  with 
pyogenic  microbes.  The  overlying  skin  remains  normal  in 
all  respects. 


LYMI'/IANaiTIS 


235 


TJk;  rollowing  table  shows  the  sitiiJilion  of 
glands  in  relation  to  the  chancre: 


hirgerl 


Chancres  of  the  genital  organ.s; 
of  the  integument  in  their 
immediiite  neiglil^orhood,  or  of 
the  anus. 

Chancres  of  the  lips  and  chin. 

Chancres  of  the  tongue. 

Chancres  of  the  eyelids. 

Chancres  of  the  fingers. 

Chancres  of  the  arm  and  breast. 


IiiguiiiMl  glands. 


Submaxillary  glands. 
Subhyoid  glands. 
Preauricular  glands. 
Epitrochlear  and  axillary  glands. 
Axillary  glands. 


Lymphangitis. — The  lymphatic  vessels  become  indurated 
about  the  same  time  as  the  chancre  and  run  from  it  toward 
the  nearest  group  of  glands.  They  are  hard  and  cord-like, 
and  devoid  of  all  acute  inflammatory  symptoms,  provided 
the  chancre  is  kept  clean;  but  if  not,  then  suppuration  may 
occur  along  their  course. 


Differential  Diagnosis  of  the  Chancre  and 


Chancroid. 


Chancre. 
Has  a  period  of  incubation; 

days  to  three  weeks. 
Looks  like  a  superficial  erosion. 


ten 


The  edges  are  sloping. 

The  floor  is  smooth,  shining,  and  red 

in  color. 
The  secretion  is  serous  and  profuse. 

The  induration  is  cartilaginous  and 
sharply  limited. 


The  neighboring  lymphatic  glands 
are  indurated,  painless,  freely 
movable  beneath  the  skin,  not 
matted  together,  and  do  not 
suppurate  unless  infection  of 
the  chancre  has  occurred. 

The  tissues  around  the  lesion  are 
purplish  in  color  from  A'euous 
congestion. 

Spirochete  are  found  in  the  dis- 
charge. 


Cliancroid. 
Has  no  period  of  incubation. 

Is  "punched  out"  and  excavated 
in  appearance. 

The  edges  are  undermined. 

The  floor  is  uneven,  "worm-eaten," 
and  yellow  in  color. 

The  secretion  is  purulent  and  auto- 
inoculable. 

There  is  no  induration,  but  the  sore 
maj^  be  surrounded  by  a  zone 
of  edematous  infiltration,  not 
sharply  limited. 

If  the  neighboring  lymphatic  glands 
are  involved,  they  form  an  in- 
flamed, painful  mass,  which 
usually  suppurates;  the  over- 
lying skin  becomes  red,  tender, 
and  hot. 

The  tissues  around  the  lesion  are 
blight  red  in  color  from  acute 
inflammation. 

No  spirochetse  are  found  in  smears. 


CHAPTER   XXII. 
TTTE  SECONDARY  PERIOD. 

Ix  some  subjects  the  commencement  of  this  period,  which 
begins  at  about  the  end  of  the  forty-fifth  to  tlic  ninetieth 
day,  is  marked  only  by  lesions  of  the  integument  and 
mucous  membranes  and  general  involvement  of  both  the 
superficial  and  deep  lymphatic  ganglia.  In  others,  there 
are  also  various  constitutional  disturbances,  such  as  fever, 
headache,  neuralgia,  pains  in  the  bones,  muscles,  or  joints, 
insomnia,  and  anemia. 

Syphilitic  fever  varies  considerably  in  different  cases, 
running  from  101°  to  102°,  or  even  as  high  as  105°  E.  It 
may  be  either  intermittent,  remittent,  or  continuous  in 
character;  as  a  rule,  it  is  higher  at  night  and  just  prior  to 
the  appearance  of  an  eruption,  after  the  development  of 
which  it  usually  subsides  spontaneously,  or  as  the  result  of 
treatment.  The  fever  may  be  accompanied  by  chilly  sensa- 
tions, or  even  a  well-marked  chill,  and  followed  })y  mild 
or  profuse  sweating;  there  is  a  corresponding  acceleration 
of  the  pulse  and  respiration.  Syphilitic  fever  is  uninfluenced 
by  quinin  and  other  antipyretics,  but  yields  readily  to 
constitutional  antisyphilitic  treatment. 

Neuralgic  pains  in  different  parts  of  the  body,  intense 
headache,  and  i>ains  in  the  bones,  joints,  tendons,  and 
muscles,  which  become  worse  at  night,  are  very  common  at 
this  period  (^f  the  disease,  esi)eciall>'  in  those  who  have 
previously  sufi'ered  from  similar  non-specific  afi'ections. 


riff':  HYi'iiiiJDKH  237 

Iiisoiiiniii,  jiccoiiipiiiiicd  l)\  \;iri<)Us  <l('liisi()iis,  is  soinctinics 
met  with. 

Anemia  diiriiii;-  this  static  is  frc(|iiciit  ly  ciiCDiiiitcrcd, 
generally  in  run-down  and  dchilitated  subjects.  There 
is  a  moderate  leukoeytosis. 

The  skin  and  mucous  membranes  are  ver\'  suseej>tible  to 
irritation  and  inflammation,  as  may  frequently  be  observed 
in  the  slow  healing  of  wounds  and  scratches,  in  untreated 
syphilitic  subjects. 

Syphilitic  disturbances  of  sensation  occur  in  l)oth  men 
and  women,  but  most  frequently  in  tlic  latter  sex.  In  some 
cases  anesthesia  extends  over  the  entire  body,  while  in 
others  it  is  restricted  to  certain  regions,  its  favorite  localities 
being  the  dorsal  surfaces  of  the  forearms,  the  hands,  the 
ankles,  and  the  feet. 

Icterus  is  sometimes  observed  during  the  secondary  stage, 
and  is  caused  by  congestion  and  edema  of  the  mucous 
membrane  of  the  common  bile  duct. 


THE  SYPHILIDES. 

The  syphilides  constitute  the  various  lesions  of  the  skin 
and  mucous  membranes  which  may  appear  at  any  time 
during  the  course  of  the  disease,  in  improperly  treated 
cases,  and  are  caused  by  a  localized  hyperemia  and  a  varying 
amount  of  cell-infiltration.  The  hyperemic  or  erythematous 
syphilides  are  peculiar  to  the  early  stages,  while  those  due  to 
cell-infiltration  appear  later.  The  infiltrating  cells  are  small, 
round,  granular,  nucleated  bodies,  resembling  somewhat 
white  blood  corpuscles,  and  very  similar  to  the  cells  found 
in  the  initial  lesion  and  the  later  gummatous  tumors. 


238  THE  SECONDARY  PERIOD 

Tlio  course  of  the  syphilides  is  chronic,  and  marked  by  the 
absence  of  acute  inflammatory  symptoms.  As  a  rule,  there 
is  no  pain  or  itching  except  Avhen  the  lesions  degenerate  or 
are  situated  on  the  scalp,  when  they  may  then  cause  more  or 
less  irritation. 

Sometimes  several  varieties  of  lesions  are  present  at  the 
same  time;  this  occurrence  is  due  to  faulty  treatment. 
Their  color,  which  is  at  first  pinkish  red,  finally  fades  to  a 
brownish  red  or  copper  color;  these  pigmentary  changes 
being  due  to  a  deposit  of  the  coloring  matter  of  the  blood 
in  the  affected  spots. 

In  the  following  descriptions  of  the  various  syphilitic 
eruptions  involving  the  skin  and  mucous  membranes, 
the  reader  must  bear  in  mind  and  clearly  understand  that, 
as  a  general  rule,  the  roseola  or  macular  syphilide  is  the 
first  and  only  eruption  commonly  seen  in  otherwise  healthy 
subjects  who  undergo  a  proper  treatment,  and  that  papules, 
pustules,  gummatous  infiltrations,  etc.,  are,  in  reality,  due 
to  tardy,  improper  and  insufficient  treatment,  or  to  some 
intercurrent  disease,  habit,  or  condition  which  undermines 
the  patient's  health  and  vitality,  thus  rendering  his  tissues 
more  vulnerable  to  the  action  of  the  spirochetfp. 

It  must  also  be  remembered  that,  with  our  modern  methods 
of  early  diagnosis  and  more  rapidly  efficient  treatment,  not 
even  the  macular  syphilide  or  roseola  will  appear,  in  the 
vast  majority  of  cases,  provided  the  patient  is  seen  early 
enough  in  the  disease. 

The  Erythematous  Syphilide. — The  erythematous  syph- 
ilide, also  called  syphilitic  erythema,  syphilitic  roseola, 
or  macular  syphilide,  is  the  first  eruption  to  appear,  and 
marks  the  commencement  of  the  secondary  period  of  the 
disease  (forty-fifth  to  the  ninetieth  day).     It  exists  in  all 


TIIIC  SYI'UIIJDICS 


289 


untreated  cases  of  syj)Iiilis,  hut  may  he  sf>  faint  and  scanty 
in  some  as  to  escape  ol)ser\'atioii. 

The  lesion  (joiisists  of  rouiuh  oval,  or  irrc|(iilar  spots  of 
hyperemia  with  a  (Hameter  of  from  one  Hue  to  half  an  inch. 
Their  color  varies  from  a  delicate  pink  to  a  decided  red  or 
even  purple  hue.  In  some  cases  there  is  only  a  mottling  of 
the  skin,  or  the  eruption  is  so  faint  as  to  be  invisible  except 


Fig.  109. — Diffuse  scaling  erythematous  sj-philide.     (Author's  case.) 


on  careful  examination.  Exposure  to  cold  brings  the  spots 
prominently  into  view,  which  can  be  accomplished  by  apply- 
ing alcohol  to  the  surface  or  having  the  patient  undress  in  a 
cool  room. 

i\.s  a  rule,  the  eruption  appears  first  near  the  umbilicus, 
then  spreads  over  the  trunk  and  extremities,  especially 
on  their  flexor  aspects;  the  dorsal  surfaces  of  the  hands  and 


240 


THE  SECONDAin'   PERIOD 


tVct  arc  rari'ly  imadrd,  Imt  the  spots  an-  \(.'ry  persistent  on 
the  ])alins  and  soles,  where  they  nia\  form  seaHng  patches 
(Fig.  l(H)j.  On  the  hack  tiie  eruj)tion  i'oUows  the  obUquity 
of  the  ribs,  from  the  mechan  hne  ontward.  When  it  occurs 
on  the  scalj)  it  is  usually  aceomi)anied  hy  alopecia.    On  the 


nftiiSi^ 

■ 

^ 
^ 

t 

V              * 

iH 

i^ 

^^^B 

■^ 

fl 

-« 

a 

■ 

km 

1 

Fl(i.  110. — f'ondvloiiiata  lata. 


genitals  of  either  sex  the  macules  may  hypertrophy,  and  thus 
form  condylomata  lata;  the  same  is  true  if  they  are  situated 
al)out  the  anus,  tlie  umbilicus,  the  nose,  the  mouth,  or  in  the 
folds  beneath  and  between  the  l)reasts,  or  where  surfaces 
of  skin  are  in  contact  (Fig.  110).     If  the  face  be  involved, 


Till']  SYl'IIIIJDh'S  241 

tlie  eruption  is  most  inurkcd  about  the  nose,  nioiitli,  diiii, 
•dud  especially  on  the  forehead,  at  the  honlcr  of  the 
scalp. 

The  eruption  ou  the  face  is  generally  covered  hy  fine 
scales  of  epidermis  or  yellowish-white  crusts. 

The  Papular  Syphilides.  -The  lesion  of  the  ])apular 
syphilides  consists  of  circumscribed  cell-infiltration  into  the 
integument. 

There  are  two  varieties  of  the  papular  syphilide:  the 
conical  or  miliary  papular  syphilide,  and  the  lenticular  or 
Hat  papular  syphilide. 

The  Conical  or  Miliary  Papular  Syphilide. — This  syphilide 
has  two  varieties:  the  large  conical  or  miliary  pajjular 
syphilide,  composed  of  large  papules,  and  the  small  conical 
or  miliary  syphilide,  composed  of  small  piapules. 

The  large  miliary  papular  syphilide  is  less  common  than 
the  small  variety,  and  is  frequently  associated  with  it.  The 
papules  are  conical,  red  m  color  at  first,  but  finally  assume  a 
coppery  hue.  They  rarely  appear  in  large  numbers,  and  are 
generally  scattered  over  the  body.  The  papules  are  most 
profuse  on  the  back  and  buttocks,  the  front  of  the  thighs, 
the  face,  and  the  back  of  the  neck.  If  untreated  they  are 
very  prone  to  pustulate  and  degenerate  into  ulcers. 

In  the  small  miliary  papular  syphilide  the  papules  are 
about  the  size  of  a  pinhead,  round  or  conical,  sometimes 
umbilicated,  and  of  a  deep  pinkish-red  color.  They  are 
grouped  either  in  the  form  of  circles,  segments  of  circles, 
or  like  the  letter  S  or  figure  8. 

The  eruption  begins  about  the  face,  and  thence  in\-ades  the 
entire  body.     Some  of  the  papules  may  be  converted  into 
\'esicles  or  pustules  by  the  formation  of  serum  or  pus  on 
their   apices. 
16 


242    ,  THE  SECONDARY   PERIOD 

The  Lenticular  or  Flat  Papular  Syphilide.  'I'Iutc  arc  two 
varieties  t)f  this  syphilide:  the  small  leiitieiilar  or  flat  i)apuhir 
syphilide,  eonijxist-d  of  small  papules,  and  the  lari^e  lentieular 
or  fiat  i)apular  syphilide,  eomi)ose(l  of  lar<;'e  papules. 

Small  Lcnticiilar  ar  flat  Pdpiihir  Sj/plillidr. — lu  this  form 
the  papules  begin  as  little  red  sjjots,  and  rapidlx'  increase  in 
size  to  one-eighth  or  even  one-quarter  of  an  inch  in  (Hanieter. 
They  are  round  or  oval,  with  flat  surfaces  and  sharply  limited 
margins.  The  papules  first  appear  about  the  shoulders,  the 
back  of  the  neck,  or  the  sides  of  the  thorax,  and  are  rapidly 
followed  by  others  on  the  face  and  the  front  of  the  neck;  the 
trunk  and  body  generally  are  then  in\aded,  and  on  the  back 
the  eruption  follows  the  course  of  the  ribs.  They  are  espe- 
cially numerous  on  the  flexor  aspects  of  the  extremities  and 
near  joints.  The  supra-  and  infraclavicular  regions  are  not 
invaded.  They  are  more  numerous  on  the  palmar  than  on 
the  dorsal  surfaces  of  the  hands. 

If  the  papules  extend  below  the  knees  they  are  sparingly 
distributed  on  the  inner  surfaces  of  the  legs,  and  sometimes 
on  the  soles.  This  syphilide  frequently  spares  the  face, 
l)ut  not  invariably. 

The  scales  on  the  papules  are  small,  adherent,  and  yellow'- 
ish  white  in  color.  Under  proper  constitutional  treatment 
this  eruption  disappears  rapidly. 

A  relapse  of  this  syphilide  may  occur  at  any  time,  in 
improperly  treated  cases,  and  the  papules  then  tend  to  form 
circles,  or  segments  of  circles,  on  the  elbow's  and  knees,  and 
may  be  accompanied  b}'  papules  on  the  shoulders  and  trunk. 

Larf/e  Lenikidar  or  Flat  Pajndar  Syphilide. — Commencing 
as  small  spots,  the  papules  increase  rapidly  in  size;  they  are 
elevated,  sharply  defined,  and  co\ered  with  small  scales;  in 
diameter  they  vary  from  three-eighths  of  an  inch  to  one  inch 


77//';  SYI'IIILIDKS 


243 


(Figs.  Ill,  112,  1111(1  I  i;!).  Tlic  (-(tlor,  wliidi  is  at  first  rerJ, 
soon  becomes  ('()])|)ery.  'riicir  course  is  ciiroiiic,  iiiiless 
checked   hy  ;ii)i)r()i)ri;ite  treatment.     Tliis  sypliilide   really 


Fig.  111. — Maculopapular  syphilidc.     (.Author's  case.) 


244 


THE  SECONDARY  PERIOD 


belongs  to  the  middle  and   late  periods  of  the  seeondary 
stage. 

The  ernption  consists  of  a  large  number  of  papules  scat- 
tered irregularly  over  the  body.     Upon  moist,  warm,  and 


Fig.  112. — Muculoijapular  syphilido.      (Author's  case.) 


unclean  surfaces  papules,  either  large  or  small,  become 
excoriated  and  transformed  into  condylomata  lata,  with  a 
foul  and  infectious  secretion.  This  occurs  most  frequently 
between  the  toes,  around  the  umbilicus,  at  the  margin  of  the 


THE  SYI'IIILIDES 


245 


nostril,  on  tin;  perineum,  iihout,  the  genitals,  and  Ix'tween 
tlu;  tliiglis  and   serotinn. 

Scaling  Papular  Syphilide  of  the  Palms  and  Soles.  Sealing 
papular  syphilide  of  thte  palms  and  soles  may  oceur  at  any 
time  during  the  secondary  period  or  with  tertiary  lesions. 


Fig.  113. — Maculopapular  syphilide.     (Author's  case.) 

Their  course  is  chronic,  painless,  and  unaccompanied  by 
itching.  The  well-marked  scaling  syphilide  of  the  palms 
and  soles  may  appear  as  early  as  the  third  month  or  much 
later.  At  first  the  papules  are  elevated,  sharply  defined,  and 
of  a  deep  red  color;  they  increase  in  size,  fuse  together,  and 
form  irregular  spots  and  patches  (see  Figs.  114,  115,  116,  and 
117). 


24(1 


Till-:  SECONDAUY   I'Kh'/oi) 


Fig.  114. — Cirouinsciibcd  .scaling  papular  syphilidc.      (Author's  case.) 


Fig.  11.5. — Diffuse  scaling  papular  syphilidc.      (Author's  case.) 


Till':  svriii LI i>Ks 


247 


Fig.  IIG. — ("ircuinscrilHil  -r.iliiMj^  iiapiilar  syphilide  of  sole. 


Fig.  117.— Scaling  papular  syphilide. 


248  THE  SECONDARY  PERIOD 

There  is  a  general  thickening  of  the  epidermis,  with  scaHng 
and  redness  of  the  snrface;  in  severe  cases  the  furrows  of  the 
hand  may  be  converted  into  painful  fissures,  wliich  are  liable 
to  last  for  months  or  even  years,  in  improperly  treated 
cases.  This  affection  may  extend  along  the  fingers  to  the 
nails,  whicli  tluni  become  brittle  and  thickened  (syphilitic 
onj'chia). 

The  Pustular  Syphilides. — These  syphilides  may  appear 
at  any  time  during  the  secondary  stage,  or  even  as  late  as 
the  tertiary  period.  The  pustules  vary  in  size,  from  that  of 
a  pinhead  to  that  of  a  ten-cent  piece;  are  round  or  oval, 
and  surrounded  by  a  coppery  zone.  They  may  begin  as 
papules  or  pustules.  In  some  cases  they  cover  the  entire 
body,  while  in  others  they  are  limited  to  special  regions. 
The  crusts  of  the  small  pustules  are  greenish  brown  in  color; 
while  those  of  the  larger  and  later  ones  are  greenish  black, 
and  somewhat  adherent.  Beneath  the  small  crusts  there  is 
little  if  any  suppuration,  but  under  the  larger  ones  there 
are  well-marked  ulcers. 

The  Small  Pustular  or  Acneform  Syphilide. — This  is  a 
papuiopustular  syphilide  and  attacks  the  sebaceous  and 
hair  follicles.  It  consists  of  small,  conical,  or  slightly  rounded 
pustules. 

The  appearance  of  this  eruption  is  usually  attended  by 
more  or  less  fever,  which  may  last  for  some  days,  the  tem- 
perature varying  from  99°  to  100°  F.,  or  over. 

In  some  cases  the  pustules  are  transformed  into  small 
ulcers;  in  others  they  run  together,  forming  complete  or 
partial  rings. 

The  eruption  usually  begins  about  the  face,  the  scalp,  the 
back  of  the  neck,  and  the  shoulders,  and  may  then  invade 
the  entire  body,  but  is  most  marked  upon  the  scapular, 


THE  HYJ'IIILIDKH  240 

steriiJiI,  iuid  <i;liil(';il  rc<;'i()ii.s,  ;iii<l  nii  the  oiifcr  iispc<'t.s  ol'  iJic 
extremities. 

This  sy])liili(le  <i;enerally  uj)peiirs  from  the  tliird  to  tin- 
sixth  month  of  tlie  secondary  period,  iind  m;i\  run  a  very 
ehronie  course;  it  rela})ses  usually  as  a  larger  j)ustular  or 
tubercuhir  sy})hilide.  The  i)ustules  leave  small  brown  spots 
of  pigmentation  which  disappear  in  a  few  months,  or  cica- 
trices which  destroy  the  luiir  follicles,  thus  profhuiiio;  perma- 
nent alopecia. 

The  Large  Pustular  or  Impetigoform  Syphilide. — This  is  a 
pustulocrustaceous  eruption,  having  a  tendency  to  involve 
large  areas  of  surface  and  to  become  serpiginous  in  character. 

It  usually  appears  about  the  middle  or  latter  part  of  the 
first  year  of  the  disease,  but  may  occur  earlier  or  later. 

Most  of  the  pustules  are  about  the  size  of  a  pea,  or  larger, 
and  found  upon  the  hairy  parts,  seldom  on  the  hands  anfl 
feet. 

The  eruption  commences  as  red  spots,  which  are  soon 
transformed  into  pustules;  these  are  covered  by  dark-brown 
adherent  crusts,  which  may  run  together,  thus  forming 
patches  that  attain  a  diameter  of  several  inches;  this  is  well 
seen  on  the  face,  at  the  margin  of  the  scalp,  in  the  scalp 
itself,  about  the  alse  nasi  and  commissures  of  the  lips,  upon 
the  chin,  and  in  the  beard. 

In  some  cases  the  eruption  becomes  serpiginous,  generally 
upon  the  upper  extremities;  it  extends  by  a  ring  of  ulcera- 
tion, covered  with  a  crust,  and  enclosing  a  healed  area  of 
skin.  This  serpiginous  process  may  be  either  superficial  or 
deep,  according  to  the  amount  and  depth  of  tissue  it  destroys. 
In  neglected  and  untreated  cases  the  ulceration  may  cause 
great  destruction  of  tissue,  especially  upon  the  face  and  head 
(Fig.  118) ;  this  is  rarely  seen,  however,  if  the  patient  receives 


2r)() 


THE  SECONDARY  PERIOD 


i-arly  and  projxT  trcatiiu-iit.  1  loalinu'  occurs  under  the  crusts, 
wliich  tall  otl",  leaving  sinoolli,  red  surfaces  that  remain 
pigmented  for  several  months. 

This  eruption  is  rarely  present  ^^ith  the  er\  theniatous 
syphilitle,  hut  is  not  uncominoii  with  the  ])a|)uhir  variety;  it 
generally  occurs  in  (lel)ilitate(l  and  alcoholic  sul)jects,  or  in 
those  who  have  neglected  early  treatment. 

The  Variolaform  Syphilide. — This  is  a  much  less  conunon 
eruption  than  the  acneform  variety,  and  resembles  variola 
and    varicella. 


Fig.  lis. — Sorpiginous  syphilide. 


It  is  composed  of  round,  superficial  pustules,  beginning  as 
red  spots,  which  in  a  day  or  so  are  converted  into  pustules. 
The  pustules  are  surrounded  by  a  deep  red  areola;  when 
fully  (kn'eloped  they  become  umbilicated.  In  al)out  a  week 
greenisli-])rown,  .slightly  adherent  crusts  are  formed,  beneath 
which  is  an  ulcerated  base. 

They'  run  a  chronic  course,  do  not  increase  in  size,  but  in 
severe  cases  may  merge  together. 

They  occur  where  the  skin  is  soft  and  delicate,  as  upon  the 
forehead,  and  at  mucocutaneous  junctions,  and  are  rarely 
found  in  the  palms  or  on  the  soles. 


'I'lIK  SVl'llf/JDh'S  251 

'Hie  cniplioii  Kevins  iihoiil  tlic  \';\c<-  iiml  s|)r('jt(l.s  rjvcr  tlio 
rest  of"  the   body. 

VVIk'Ii  tlic  crnsts  l';ill  oil',  tlicir  I'oniicr  sites  arc  iiidiratcd  1)\- 
spots  ol"  pi^iiiciitalioii. 

The  Ecthymaform  Syphilide.  Tlicre  are  two  forms  of  tliis 
syphilide     the   suixTficiul    and    the   deep. 

The  superficial  form  may  appear  at  any  time  (hirin^^  the 
first  year  of  syphihs,  and  consists  of  ])ustules;  these  begin  as 
red  ehnations  of  the  skin,  which  are  soon  transformed  into 
pustules;  tliese  increase  in  size  and  are  covered  by  round  or 
conical  crusts  of  a  yellowish-i)rown  color.  Beneath  the  crust 
is  an  ulcerated  surface,  which  secretes  a  thick  pus. 

The  pustules  generally  appear  first  about  the  scalp, 
particularly  at  its  junction  with  the  face  and  neck,  and  in  a 
short  time  invade  the  various  parts  of  the  body,  as  the 
anterior  surfaces  of  the  legs  and  forearms,  the  trunk,  and 
the  inguinal  and  gluteal  regions.  The  pustules  may  be  dis- 
seminated, grouped  in  patches,  or  arranged  in  the  form  of 
circles  or  segments  of  circles.  In  some  cases  they  leave 
cicatrices,  while  in  others  they  do  not. 

The  deep  form,  of  this  syphilide  is,  as  a  rule,  a  late  manifes- 
tation, but  may  be  precocious,  and  is  then  very  malignant. 

The  eruption  begins  as  round  or  oval  elevations,  upon 
which  pus  forms;  this  dries  into  a  blackish-brown  crust, 
having  beneath  it  a  deep,  sharply  defined  ulcer,  which,  when 
healed,  leaves  a  white  cicatrix. 

When  the  eruption  is  matured,  it  consists  of  an  incrusted 
papulotubercle,  from  one-quarter  to  one-half  inch  in  diam- 
eter, and  surrounded  by  a  copper-colored  zone. 

It  is  most  marked  upon  the  anterior  surfaces  of  the  legs, 
the  arms,  about  the  face,  and  on  the  lower  portions  of  the 
trunk. 


252 


THE  SECONDARY  PERIOD 


Rupia.-  This  ("luption  consists  of  ulcers  covered  by 
laminated  crusts.  It  nui\-  ai)i)car  during  the  first  year  of 
syphilis,  but  is  usually  a  late  manifestation  of  the  disease. 

There  are  two  varieties  of  rupia;  one  in  which  the  crusts 
are  small,  numerous,  and  scattered;  another  in  which  they 
are  larger,  less  mnnerons,   and   <;T()Ui)ed   together. 


■^.- 


FiG.  119.— Rupia.     (Taylor.) 


The  small  variety  (see  Fig.  119),  begins  about  the  face 
or  the  forearms,  and  may  then  invade  the  trunk  and  the 
lower  extremities. 

The  large  variety  is  most  common  on  the  face  and  trunk, 
but  may  also  appear  on  the  extremities. 

The  lesion  begins  as  a  red  spot  which  is  transformed  into  a 
fiat   pustule;   this  soon  dries  into  a  small  greenish-brown 


THE  SYPflfLIDES  253 

crust,  having  beneath  it  an  iileerated  surface,  the  secretion 
from  which  forms  another  and  hirger' crust  under  the  initial 
one;  this  process  continues,  each  crust  being  larger  than  the 
preceding  one,  until  finally  we  have  a  conical,  laminated, 
brownish-black,  hard,  adherent  crust,  beneath  which  is  an 
undermined  ulcer,  with  a  foul,  purulent  secretion  and  sur- 
rounded by  an  area  of  redness. 

The  lesion  is  often  single,  although  a  number  may  be 
formed  at  the  same  time. 

The  resulting  cicatrices  are  shining  white,  depressed,  and 
surrounded  by  a  brownish  line  of  pigment  which  may  remain 
for  some  time. 

The  Bullous  Syphilide. — This  syphilide  is,  as  a  rule,  a  late 
manifestation.  It  begins  as  an  effusion  of  serum  beneath 
the  epidermis,  which,  becoming  turbid,  is  finally  converted 
into  pus.  The  pus  gradualh'  dries  into  an  adherent  greenish- 
black  crust,  beneath  which  is  an  ulcer. 

The  bullae  vary  greatly  in  size  and  are  surrounded  by  a  red 
areola.  They  generally  occur  on  the  forearms  and  legs,  but 
may  also  invade  the  trunk,  and  are  then  most  marked  upon 
the  chest. 

The  Tubercular  Syphihde. — The  tubercular  s^^jhilide 
consists  of  circumscribed  or  diffuse  infiltration  involving 
the  entire  thickness  of  the  skin. 

It  really  belongs  to  the  tertiary  period,  but  may  appear 
in  the  secondary  stage. 

The  non-ulcerative  or  resolutive  tubercular  syphilide  occurs 
in  two  forms:  (1)  as  sharply  defined,  conical,  or  rounded 
tubercles,  and  (2)  as  more  or  less  elevated,  flat,  sharply 
circumscribed,  and  often  scaly  patches.  As  a  rule,  these 
lesions  do  not  ulcerate. 

The  conical  or  rounded  tubercles  varv  in  size  from  one- 


254 


THE  SECONDARY  PERIOD 


third  of  an  inch  to  an  inch  or  more  in  diameter,  and  are 
deeply  seated  in  the  derma.  They  he,u;in  as  j)iid<isli  or 
ilark  red  spots,  and  eventually  become  deep,  circumscribed 
tubercles  of  a  pinkish-red,  or  brownish-red  color.  On  the 
face  they  have  a  smooth,  shining  surface,  with  little  or  no 


Fil;.  120. — TulxTcular  .syplulide.      (Authur'b  case.) 


scaling,  but  upon  other  regions  they  are  frequently  covered 
with  large  adherent  scales  (Fig.  120). 

If  this  syphilide  appears  in  the  secondary  j)eriod,  it  usually 
invades  the  entire  body;  but  if  it  occurs  later,  it  shows  a 
tendency  to  attack  the  face,  the  forehead,  the  scalp,  the 


TIIK  SY/'IUl.fDh'S  2')') 

back  of  the  neck,  tlic  slioiiMcrs  iiiid  scjipiihir  regions,  the 
thorax,  and  ('sjx'cially  tlic  hack,  the  fj;liitcal  regions,  the  outer 
aspects  of  the  extremities  near  the  joints,  and  tlie  l)acks  of 
the  hands,  very  rarely  the  palms  anrl  soles. 

The  second  form  consists  of  flat,  sliarj)]y  circumscribed, 
deeply  seated  patches,  and  is  less  fre(|nent  than  the  first 
form.  It  connnences  as  small  red  spots  whicii  increase  in 
size  from  one  to  two  inches  in  area.  The  tnberclcs  are 
slightly  elevated,  and  look  like  patches  of  thickened  ;iiid 
reddened  skin  covered  with  scales,  and  surroniuh*!  hy  a 
narrow  areola  of  redness. 

Exceptionally,  they  form  circles,  or,  if  irritated,  patches, 
which  may  increase  at  the  periphery  and  atro])liy  at  tlie 
centre. 

On  parts  snbject  to  friction  or  pressure  the  tubercles 
sometimes  ulcerate. 

The  Gummatous  Syphilides. — There  are  two  varieties  of 
these  syphilides:  the  early  secondary  or  precocious  gummata, 
and  those  occurring  late  in  the  disease  and  called  tertiary. 

Of  the  early  secondary  or  precocious  gummata  there  are 
three  varieties:  the  generalized,  the  localized,  and  the 
neurotic. 

The  generalized  variety  may  appear  as  early  as  the  eighth 
week  or  as  late  as  the  middle  of  the  second  year  of  the 
disease. 

It  begins  as  small  circumscribed  swellings  beneath  the 
skin,  which  soon  adhere  to  it  and  form  bright  red  spots 
about  the  size  of  a  bean.  As  they  increase  their  color  be- 
comes coppery.  When  fully  developed  they  are  firm  in 
consistence;  but  as  they  mature  they  become  softer. 

If  the  disease  progresses  favorably,  these  lesions  do  not 
ulcerate,  but  resolve,  leaving  spots  of  pigmentation. 


256  THE  SECONDARY  PERIOD 

This  eruption  may  bo  <!;eneral  and  InNohe  the  entire  body. 
Its  favorite  sites  are  the  arms,  the  forearms,  the  back,  tlie 
chest,  the  ghiteal  regions,  the  thighs,  and  the  legs. 

If  ulceration  takes  place,  the  tumors  become  dark  red  in 
color  and  fluctuating,  the  integument  is  destroyed,  and 
thus  is  revealed  an  unhealthy,  undermined  ulcer,  secreting 
sanious  ])us. 

The  localized  variety  usually  appears  about  the  fifth  month 
or  within  the  first  year,  and  in  some  instances  even  later. 
The  tumors  are  the  same  as  in  the  first  variety,  except  that 
they  are  larger  and  more  indolent. 

The  eruption  is  generally  found  on  the  head,  the  face,  the 
pharyngeal  walls,  the  mouth,  the  forearms,  and  the  legs,  but 
may  also  be  met  with  upon  the  trunk,  the  arms,  and  the  thighs. 

These  tumors  likewise  have  the  stages  of  condensation 
and  softening;  they  may  either  be  absorbed  t)r  ulcerate. 

The  generalized  and  localized  varieties  of  gummata  occur 
in  elderly,  debilitated,  and  alcoholic  subjects. 

In  the  neurotic  variety  the  syphilide  appears  during  the 
\'ery  early  months  of  the  disease,  is  preceded  or  accompanied 
♦by  severe  neuralgic  or  rheumatic  pains  in  the  joints  or 
muscles,  and  by  general  malaise  and  debility.  There  are 
flashing,  burning  pains,  either  intermittent  or  continuous, 
at  the  sites  of  the  lesions.  There  are  also  some  rise  of  tem- 
perature, loss  of  appetite,  and  emaciation.  The  tumors 
generally  occur  on  the  forearms  and  legs,  but  may  be  found 
upon  the  shoulders,  the  arms,  tiie  thighs,  the  chest,  and  the 
trunk. 

This  crui)tion  consists  of  two  lesions:  (1)  of  o\al  or  round 
tumors  or  irregular  plaques,  and  (2)  of  tumors  situated 
in  the  subcutaneous  tissue  and  freely  ni()\al)le  beneath  the 
skin  and  upon  the  fascia. 


77//';  SYI'IIILI DKS  257 

The  tumors  hv\i^\\\  \)\  iiifiltriitioii  into  tlu;  skin  nnd  con- 
nective tissue;  at  first  tliey  are  bright  red,  round,  or  oval, 
circumscril)ed  swelHngs,  whicli  soon  })ecome  raised  above  the 
level  of  the  surrounding  integument. 

In  some  cases  the  bright  red  color  bcconics  darkened  into 
a  blackish  red,  in  others  into  a  deej)  bright  red,  and  again  in 
others  the  centre  becomes  wliitc  and  is  surrounded  by  a 
deep  red  border. 

Some  cases  resolve,  others  ulcerate,  and  if  the  latter  be 
the  case  the  resulting  cicatrices  are  usually  superficial. 

Late  or  Tertiary  Gummata. — These  lesions  belong  to  the 
late  stages  of  the  disease,  and  consist  of  circumscribed  tumors. 

The  eruption  is  composed  of  a  small  number  of  lesions 
whose  course  is  slow  and  painless.  It  generally  occurs  on 
parts  where  the  connective  tissue  is  loose  and  abundant. 

When  the  lesions  are  subcutaneous  they  are  gummous  or 
gummatous  tumors;  but  if  they  ulcerate  and  involve  the  skin 
they  are  called  gummatous  ulcers. 

This  syphilide  has  three  stages:  the  stage  of  tumefaction, 
the  stage  of  ulceration,  and  the  stage  of  repair. 

It  commences  as  painless,  movable  nodules  about  the  size 
of  a  pea,  and  situated  beneath  the  integument.  As  they 
increase  in  size  they  form  adhesions  with  the  skin,  periosteum, 
and  fascia. 

The  integument  over  the  nodules  is  at  first  red,  but  finally 
becomes  coppery  red  and  much  thickened. 

The  lesions  are  true  gummy  tumors,  varying  in  size  from 
that  of  a  pea  to  several  inches  in  diameter,  more  or  less  con- 
vex and  surrounded  by  an  area  of  inflammation.  They  are 
prone  to  develop  in  groups,  and  may  either  fuse  together  or 
remain  isolated.  The  tumors  may  remain  solid  for  weeks  or 
months,  but  with  proper  treatment  then  undergo  resolution. 
17 


•258 


THE  SECONDAh'Y  PERIOD 


Asa  rule,  they  degenerate  in  either  of  the  tdllowiiigways:  By 
ulceration,  which  may  oeeiir  on  the  skin  and  inxoKe  tlie 
entire  lesion,  or  the  new  i;Towth  may  soften  and  cause  ulcera- 
tion in  the  skin.  The  resultiny;  ulcer  is  similar  in  shape  to  the 
tumor;  the  floor  is  une\en,  reddish  green  or  yellowish  green 
in   eolor,   and   secretes  sanious,   fetid    pus.     The  edges  are 


( 

V,, 

r 

■\ 

\             * 

^% 

\ 

"^^ 

X 

1 

Fig.  121. — Gummatous  ulocr.s.      (Author's  case.) 


sharply  cut,  perpendicular,  and  surrounded  by  an  inflam- 
matory areola  (Fig.   121). 

The  cicatrices,  which  are  thin  in  some  cases,  but  thick  and 
rough  in  others,  soon  lose  their  coppery  color  and  become 
white. 

This  syphilide  may  occur  on  the  scalp,  the  face,  or  the 
neck;  its  favorite  sites  are  on  the  extremities,  near  the 
joints,  the  back  more  frequently  than  the  chest,  very  often 


THE  SYf'll/fJDf'JS 


250 


upon  the  j^lut.ciil  rcj^ioiis,  rarely  ii|)()ii  the  lower  jjarl,  oi'  the 
aJ)(loiiieii,  never  on  the  |)alni.s  or  soles. 

The  Serpiginous  Syphilide.     'I'liere  arc  t\v(^  \arieties  of 
this  syphiUde:  tlio  su])crHeial   and   tlie  deep. 


Fig.  122. — Serpiginous  syphilide.     (Taylor.) 


The  superficial  serpiginous  sypliihde  belongs  to  the  early 
period  of  syphilis,  and  begins  as  a  pustule;  a  crust  forms 
upon  it,  beneath  which  is  a  superficial  ulceration ;  the  crusts 
fall  off  except  at  the  periphery,  where  they  form  a  ring,  the 
enclosed  area  being  oval  or  round  in  shape  and  hyperemic. 


260  THE  SECONDARY  PERIOD 

Beneath  the  ring  of  crusts  is  a  correspoiuhiig  ulcer,  sur- 
rounded by  an  inflammatory  areola.  The  ulcerative  process 
extends,  being  covered  by  the  crusts,  while  the  central 
portion  cicatrizes.  When  ulceration  ceases,  it  leaves  slight 
atrophy  of  the  skin  and  copper-colored  pigmentation. 

The  deep  serpiginous  syphilide  originates  in  one  of  the 
late  or  tertiary  lesions,  such  as  a  tubercle,  an  ectliymaform 
pustule,  or  an  ulcerating  gumma. 

Changes  similar  to  those  in  the  superficial  variety  take 
place  until  there  is  de\'eloped  a  red  cicatrix  surronnrled  by  a 
wide  ring  of  greenish-black  crusts,  beneath  which  is  an 
ulcerating,  ring-shaped  surface  (Fig.  122). 

It  usually  occurs  on  the  inner  surfaces  of  the  arms  and 
forearms,  upon  the  breast  and  the  legs. 

The  resulting  cicatrices  may  be  thick  or  thin,  and  if 
situated  near  joints  they  are  liable  to  cause  permanent 
deformity  from  their  contraction.  The  pigmentation 
finally  fades,  leaving  whitish  scars. 

The  Pigmentary  Syphilide. — This  syphilide  occurs  in  the 
early  months  of  the  disease  and  consists  of  brown  or 
yellowish-brown  spots  or  patches. 

There  are  three  forms  of  the  pigmentary  syphilide: 

The  first  form  consists  of  sharply  defined  or  irregular  spots 
or  patches,  of  a  yellowish-brown  or  brown  color,  which  is 
unaffected  by  pressure.  They  vary  in  size  from  that  of  a  pea 
to  an  inch  or  even  more  in  diameter,  are  not  elevated,  and 
do  not  scale. 

The  second  form  occurs  as  a  diffuse  ])igmentation,  and  is 
more  common  than  the  first  variety.  It  usuallv'  begins  on 
the  sides  or  the  back  of  the  neck,  and  thence  invades  the 
chest  and  back  for  a  short  distance.  The  color  varies  in 
diff'erent  subjects,  from  a  ^^e^y  light  to  a  light  brown  or  even 


THE  SYPJ/ffJDf'JS  201 

a  decidedly  hrovvii  Iiik;.  Upon  the  siirfiu.'c  of  ii,  pjitdi  iippcar 
several  small,  round,  oval,  or  irregular  white  sp(;ts;  these 
increase  slowly,  in  some  cases  becoming  whiter  than  the 
normal  skin,  while  in  others  they  are  of  the  same  color. 

The  third  form  consists  of  an  iihnornKil  distribution  of  \\\c 
pigment  of  the  skin,  and  is  the  least  connnon  of  all. 

The  normal  color  of  the  integument  becomes  white,  in 
spots  of  irregular  size  and  shape;  the  spots  are  surrcdindcd 
by  a  dark  border,  which  becomes  deei:)er  in  color  as  the  w  hite 
spots  increase. 

The  lesion  may  appear  as  early  as  the  second  or  third 
month,  but  usually  occurs  at  the  sixth  month,  and  during 
the  second  or  even  the  third  year. 

This  syphilide  is  generally  situated  upon  the  neck,  and 
especially  its  sides,  less  frequently  upon  the  forehead  and 
face,  but  may  also  appear  upon  the  flexor  surfaces  of  the 
extremities. 

Malignant  Precocious  Syphilides. — By  malignant  preco- 
cious syphilides  are  understood  certain  eruptions,  which, 
having  a  malignant  ulcerative  tendency,  appear  early  in 
the  course  of  the  disease,  and  are  accompanied  by  general 
cachexia. 

Occurrence. — Pustular  eruptions,  particularly  the  impetigo- 
form  and  the  ecthymaform  syphilides,  and  less  frequently 
the  papular  eruptions,  are  prone  to  assume  these  characters. 
Such  complications  generally  occur  in  debilitated  and  sickly 
subjects,  in  those  addicted  to  alcoholic  stimulants,  or  suffer- 
ing from  some  form  of  severe  and  exliausting  intercurrent 
disease.  A  faulty  treatment  is  also  a  causative  factor  in 
some  cases. 

These  syphilides  are  divided  into  three  distinct  varieties. 
The  first  is  a  pustular  eruption,  accompanied   b\'  ulcera- 


262  THE  SECONDARY  PERIOD 

tion  and  crust-formation.  It  commences  as  pustules,  which 
ulcerate  and  form  greenish-l)l;uk  crusts;  the  ulcers  are  deep 
and  have  a  foul,  purulent  secretion.  Beginning  upon  the 
face  or  scalp,  it  extends  to  the  arms,  and  ma\-  e\ciitually 
invade  other  parts  of  the  body. 

The  second  begins  as  small  tubercles,  which  are  rai)idly 
transformed  into  ulcers,  covered  by  thick  crusts.  Its  course 
and  situation  are  similar  to  the  preceding  class. 

The  third  variety  is  a  very  destructive  and,  fortunately, 
quite  uncommon  syphilide. 

It  commences  as  dark  red,  deeply  seated  tubercles,  in  the 
centre  of  which  a  black  slough  forms;  it  increases  in  size, 
and  is  thrown  off,  exposing  a  deep  undermined  ulcer,  with 
foul,  ichorous  secretion.  Each  tubercle  is  surrounded  by  a 
zone  of  redness.  When  healing  occurs  a  depressed,  copper- 
colored  cicatrix  is  left,  w^hich  in  time  becomes  white.  The 
eruption  is  situated  upon  the  face,  the  extremities,  the 
shoulders,  and  the  buttocks. 


CHAPTER  XXIII. 
SYPHILIS  OF  'n\K   APPENDAGES  OF  TUK  SKIN. 

THE  HAIR. 

Syphilitic  alopecia  is  rarely  encountered,  and  then  to  a 
limited  extent  only,  in  cases  that  have  received  early  and 
appropriate  treatment.  It  may  be  either  slight  or  quite 
extensive,  and  runs  a  rapid  course  in  some  cases  and  a 
chronic  one  in  others. 

As  a  general  rule,  it  is  unaccompanied  by  heat  or  itching. 
There  may  be  no  marked  lesions  of  the  scalp,  or  there  may 
be  macules,  papules,  pustules,  or  ulcers. 

The  eyebrows,  the  beard,  and  the  moustache,  the  hair  of 
the  pubes,  the  axillae,  and  that  on  the  body  generally  may  be 
involved;  the  eyelashes  are  seldom  attacked,  unless  by  an 
ulcerative  lesion. 

There  are  two  varities  of  syphilitic  alopecia:  (1)  a  general 
thinning  of  the  hair;  (2)  loss  of  the  hair  in  spots  or  patches 
of  irregular  size  and  outline. 

Alopecia  is  the  result  of  impaired  nutrition  of  the  hair- 
follicles,  and  is  usually  transitory.  Permanent  baldness 
may  result,  however,  from  ulcerative  processes  attacking 
and  destroying  the  hair  follicles. 

THE  NAILS. 

Syphilitic  lesions  of  the  nails  are  of  two  varities:  (1) 
onychia,  in  which  the  disease  begins  in  the  substance  of  the 


■2G4       SYPHILIS  OF   THE  APPENDAGES  OF   THE  SKIN 

nail;  (2)  pcrionychia,  in  which  the  disease  commences 
around  the  nail,  and  finally  involves  it  (see  Figs.  123  and 
121V 


Fk;.  123. — Onychia.      (Author 's  ca.-ic; 

Onychia. — In  syphilitic  onychia  the  process  may  be  dry 
and  limited  to  the  nail,  or  the  nail  may  be  separated  from 
its  bed  by  a  moist,  exudative  process. 


'^   if* 


Fig.  124. — Onychia  of  thumb  nails.      (Author's  case.) 

In  dry  onychia  the  nail  loses  its  lustre  and  transparency 
and  becomes  dull  yellow  in  color.  The  disease  inaj'  be 
limited  by  a  line  of  demarcation,  or  involve  the  entire  nail. 


77//';  NAII.S  205 

The  edge  of  tlic  iiiiil  l)eeoiries  tliiek,  brittle,  ;iii'l  fnicks 
readily;  its  surfiicc!  is  roiigli  uiid  iruirked  by  sliiillow,  longi- 
tudinal fissures  and  depressions;  the  surrounding  ei)ideruiis 
is  generally  thiek  and  sealy. 

The  diseased  portion  is  gradually  puslie<l  for\\;ird,  grf)\vs 
out,  and  is  replaced  by  healthy  nail  tissue. 

Separation  of  the  nail  may  be  partial  or  coniijlete  and 
generally  oecurs  in  the  early  part  of  the  secondary  stage. 

It  begins  at  the  free  border  of  the  nail,  and  gradually  creeps 
toward  its  base,  the  diseased  area  becoming  greenish  brown  in 
color.  If  only  a  portion  of  the  nail  has  been  destroyed,  the 
healthy  part  pushes  forward  and  covers  the  denuded  space; 
but  if  destruction  has  been  complete,  an  entirely  new  nail  is 
formed. 

One  or  several  nails  may  be  affected;  those  of  the  fingers 
more  frequently  than  the  toes. 

Perionychia. — There  are  two  varieties  of  syphilitic  peri- 
onychia:  the  non-ulcerative  and  the  ulcerative  forms. 

The  non-ulcerative  form  attacks  a  portion  of  or  the  entire 
attached  border  of  the  nail,  which  becomes  infiltrated  and 
thickened;  this  condition  may  persist  until  the  nail  loses 
its  lustre  and  is  marked  by  transverse  furrows.  Ulceration 
sometimes  occurs  where  the  skin  is  reflected  from  the  nail, 
and  extending  beneath  it  causes  it  to  loosen  and  fall  oft'. 

The  ulcerative  form  may  begin  as  a  papule,  pustule, 
ulceration,  or  fissure  at  some  part  of  the  nail  margin,  and 
spread  beneath  it,  secreting  a  foul  pus.  The  whole  nail  may 
be  destroyed,  or  only  a  portion  of  it;  but  if  the  process  be 
checked  a  new  nail  forms  and  pushes  the  old  one  out  in 
front  of  it. 

If  the  ulceration  is  severe,  the  entire  matrix  becomes 
involved;  the  nail  is  thrown  off,  leaving  a  yellowish  surface, 


266  SYPHILIS  OF   THE  APPENDAGES  OF   THE  SKIN 

surrounded  l)y  an  ulcerated  and  inflamed  border.  In  sueli 
cases  the  entire  phalanx  is  swollen. 

Unless  the  ulcerative  process  has  been  too  severe,  a  new 
nail  is  produced,  which,  after  a  little  time,  may  become  quite 
as  good  as  the  normal  one. 

There  is  sometimes  a  local  necrosis  of  the  nails,  which 
become  white  in  spots  about  the  size  of  a  pinhead;  these 
are  finally  depressed  and  extend  to  the  matrix,  leaving 
sharply  cut  holes  in  the  nail. 


CHAPTER  XXIV. 
SYPHILIS  OF  THE  MUCOUS  MEMBRANES. 

ERYTHEMA. 

Erythema  of  the  mucous  membranes  may  occur  at  any 
time  during  the  course  of  syphihs,  particularly  in  the  first 
few  months;  it  is  similar  to  that  of  the  skin,  but  is  modified 
by  the  moisture  and  irritation  to  which  mucous  membranes 
are  subjected.  It  most  frequently  involves  the  fauces  and 
pituitary  membrane. 

There  may  be  a  simple  redness  of  the  mucous  membrane 
without  swelling,  or  redness  with  edema  of  the  parts.  In 
the  more  advanced  cases  the  mucous  membrane  has  a 
milky  appearance,  its  epithelium  becomes  detached  in 
spots,  thus  causing  erosions  of  the  surface,  which  in  some 
cases  is  dry,  while  in  others  it  is  covered  by  an  abundant 
secretion  which  renders  the  saliva  very  infectious,  owing 
to  the  large  number  of  spirochetes  it  contains,  a  fact  which 
must  be  made  very  clear  to  the  patient. 

MUCOUS  PATCHES. 

Mucous  patches,  also  called  mucous  papules,  consist  of 
flat,  or  slightly  convex,  pearl-colored  elevations,  whose  surface 
resembles  mucous  membrane,  and  whose  secretion  is  highly 
contagious. 

They  are  situated  on  the  inside  of  the  cheeks,  particularly 
at  the  angles  of  the  mouth,  upon  the  lips,  the  tongue,  the 


268        SYPHILIS  OF  THE  MUCOUS  MEMBRANES 

gums,  the  inula  and  the  tonsils,  at  the  openings  of  the 
nares,  on  the  pillars  of  the  fauces,  the  hard  and  soft  palate, 
and  upon  the  conjmictiva  and  the  umbilicus. 

They  are  one  of  the  earliest  and  most  freciuent  secondary 
manifestations  of  syphilis.  The  lesion  consists  of  a  hyper- 
plasia of  the  ])apill;v  and  a  proliferation  of  cells  in  the  mucous 
layer;  the  epithelium  on  the  surface  of  the  patch  may  remain 
intact  or  become  detached,  the  surface  being  depressed  by 
ulceration  or  raised  by  further  development  t)f  the  papilla?. 

Uncleanliness,  irritation,  heat,  and  moisture  favor  their 
de\'elopment,  as  do  also  the  use  of  alcohol  and  tobacco  and 
a  rough  and  uncleanly  condition  of  the  teeth. 

Mucous  patches  within  the  mouth  are  of  a  grayish-white 
color,  looking  as  if  the  mucous  membrane  had  been  touched 
with  nitrate  of  silver  or  pure  carbolic  acid.  They  are  irregular 
in  outline,  and,  as  a  rule,  not  elevated;  when  situated  upon 
the  tonsils,  they  usually  ulcerate,  owing  to  the  constant 
friction  to  which  these  organs  are  subjected. 

CONDYLOMATA. 

Condylomata  are  in  realty  nothing  more  than  exaggerated 
mucous  patches,  which,  from  their  situation  ui)()ii  the  integu- 
ment around  the  anus  and  genital  organs,  are  altered  in 
appearance  (see  Fig.  110).  They  consist  of  round  disks, 
either  single  or  multiple,  of  a  reddish  or  grayish  color,  with 
granular  surface  and  elevated  above  the  surrounding  parts. 
They  begin  as  small  red  spots,  whose  epidermis,  being 
removed  by  friction,  leaves  a  moist,  grayish  surface,  which 
is  finally  converted  into  an  elevated  wart-like  disk,  with 
offensive  secretion  loaded  with  spirochetes,  which  render  it 
highly  contagious. 


CHAPTER  XXV. 
SYPHILIS    OF    THE    DIGESTIVE   ORGANS. 

THE  MOUTH. 

Besides  erythema  and  mucous  patches  of  these  parts, 
above  alluded  to,  papules  may  occur  in  the  mouth  during  a 
general  papular  eruption.  Vesicles  are  very  rare  in  this 
situation,  however,  owing  to  the  constant  moisture  and 
friction,  which  prevents  their  formation. 

Near  the  angles  of  the  mouth,  especially  in  habitual 
smokers,  are  frequently  seen  patches  called  smokers'  patches 
or  plaques.  They  consist  of  an  accumulation  of  epithelial 
cells,  which  becomes  whitish  in  color,  and  in  some  instances 
fissured  or  eroded. 

THE  TONGUE. 

The  secondary  or  early  lesions  of  the  tongue  consist  of 
erythema  of  its  mucous  membrane,  mucous  patches,  and 
fissures.  They  yield  readily  to  appropriate  treatment,  but 
are  very  liable  to  recur,  especially  in  smokers  and  drinkers, 
and  in  those  with  rough  and  decayed  teeth. 

Erythema  of  the  tongue  may  involve  the  entire  organ, 
or  be  limited  to  patches  which  are  scattered  over  its  surface. 

INIucous  patches  are  usually  situated  upon  the  sides  or  tip 
of  the  tongue,  and  resemble  similar  lesions  situated  on  other 
mucous  membranes. 


270  SYPHILIS  OF   rilE  DIGESTIVE  ORGANS 

Fissures  of  tin-  toiiuue  are  the  result  of  erythema  or 
mucous  patches,  and  arr  iisuallx'  situated  on  its  sides  or 
dorsum. 

Sclerosis  of  the  tongue  may  develop  in  tiie  later  stages 
of  the  disease.  It  occurs  upon  the  dorsnm,  and  is  either 
superficial  or  deej)  in  character. 


Fig.  125. — Tertiary  syphilis  of  tongue  (sclerosis).     (Author's  case.) 

Superficial  sclerosis  in\olves  only  the  uuicous  meiubrane, 
and  ])roduces  a  "parchment"  induration.  It  is  either  cir- 
cumscribed or  diffuse,  and  ulcerates  only  when  injured  by 
the  teeth  or  irritated  by  alcohol  and  tol)acc(). 

Deep  or  parenchymatous  sclerosis  (Fig.  125)  attacks  the 
mucous  and  muscular  tissues.  The  tongue  may  be  greatly 
increased  in  size,  but  after  a  time  the  newly  formed  fibrous 


77//';  'roNdUii  271 

tissue  rctriicts  and  tlic  or^^aii  becomes  atro})liic(l.  'I'lic  cclges 
of  the  t<)ii<;iie  reccixc  the  inarkinjfs  of  the  tcetli,  while  the 
body  is  lohiilated.  The  h)hnles  tire  sej)arated  \)\  furrows 
which  eanuot  he  effaced.  Ulceratiou  may  ensue  from  irrila- 
tion  or  injury. 

Gummata  may  l)e  either  suj)erfieial  or  parenchymatous. 

Superficial  or  mucous  gummata  commence  as  small  nodules, 
which  soon  soften  and  ulcerate.  The  ulcer  has  perpendicular 
walls,  infiltrated  base,  and  its  floor  is  covered  with  a  yellowish- 
white  film. 

Parenchymatous  gummata  begin  as  small  nodules  in  the 
muscular  tissue  of  the  tongue;  they  undergo  degeneration 
and  finally  the  mucous  membrane  covering  them  ruptures, 
leaving  a  deep  cavity,  with  sloughing  undermined  walls,  and 
surrounded  by  an  indurated  areola. 

The  differential  diagnosis  between  syphilitic  ulcers  or 
gummata  of  the  tongue  and  those  of  nOn-specific  origin  is 
very  important  and  oftentimes  difficult,  cases  having  been 
reported  in  which  gummata  and  gummatous  ulcers  were 
thought  to  be  cancerous,  and  the  tongue,  in  part  or  in  totality, 
removed. 

The  Wassermann  reaction,  examination  of  smears  from 
the  ulcers  for  spirochetes,  and  the  sectioning  of  tissue  excised 
from  the  lesion  may  all  have  to  be  resorted  to  to  settle  the 
diagnosis. 

The  initial  lesion  is  usually  situated  at  or  near  the  tip  of 
the  tongue  (see  Fig.  107),  is  single,  surrounded  by  induration, 
and  the  lymphatic  glands  in  anatomical  connection  are 
markedly  enlarged  and,  as  a  rule,  do  not  suppurate.  Dark- 
field  examination  of  smears  from  the  ulcer  will  repeal  the 
Spirocheta  pallida.  In  this  connection  it  is  well  to  remember 
the  possible  presence  of  the  Spirocheta  refringens,  in  order 


272  SYPHILIS  OF  THE  DIGESTIVE  ORGANS 

to  ;ivt)iil  a  mistake  in  the  diagnosis  of  the  i)articiilar  spiro- 
cheta  found. 

Gunimata  are  insidious  in  tlieir  origin,  chronic  in  their 
course,  and  generally  free  from  jiain.  They  are  situated 
n])on  the  dorsum  and  i)osterior  half  of  the  tongue  near  the 
median  line.  The  lymphatic  glands  are  rarely  affected,  and 
the  functions  of  the  tongue  are  not  interfered  with. 

Gummatous  ulcers  are  usually  multiple  and  situated  upon 
the  dorsum.  The  floor  is  sloughy  and  slightly  vascular,  and 
the  edges  are  undermined.  Lymphatic  enlargement  is  rare 
unless  pyogenic  infection  occurs.    They  cause  some  pain. 

It  must  always  be  borne  in  mind  by  the  physician,  that  late 
secondary  and  tertiary  lesions  of  the  tongue  have  a  marked 
tendency  to  malignant  degeneration,  and  that  they  should  be 
promptly  and  energetically  treated,  and  not  allowed  to 
become  chronic  and  ulcerating  in  character. 

Tubercular  ulcers  of  the  tongue  are  painful;  they  are 
usually  situated  at  or  near  its  tip  or  edge;  they  are  generally 
single,  but  may  be  multiple.  The  lymphatic  glands  may  or 
may  not  be  affected.  The  ulcer  has  bevelled  edges,  flabby 
granulations,  and  is  not  surrounded  by  induration.  The 
microscope  seldom  shows  tubercle  bacilli,  but  particles  of 
caseous  matter  may  be  seen.    They  may  occur  at  any  age. 

Carcinoma:  The  ulcer  is  single,  very  painful,  and  situated 
on  the  borders  and  anterior  half  of  the  tongue;  its  edges  are 
raised  and  hard,  and  the  surrounding  tissues  are  thickened. 
The  floor  is  very  vascular,  bleeds  readily,  and  secretes  an 
ichorous  pus.  The  functions  of  the  tongue  are  interfered 
with.  The  lymphatic  glands  are  always  enlarged.  The 
microscope  shows  cancer  cells  in  the  sections  from  the 
gro\^"th.  The  condition  usually  appears  in  patients  over 
forty  years  of  age. 


77//';   t'llAllYNX  273 

GUMMA  OF  THE  SOFT  PALATE. 

Ill  this  iiil'cctioii  |)rciii()iiit,()ry  symptoiiis  arc  iiisi^niificiuit 
or  entirely  ul)seiit.  Suddenly  the  voice  becomes  trans- 
formed into  a  nasal  whisjxT,  and  attempts  at  swallowing 
liquids  or  solids  are  followed  hy  their  regurgitation  through 
the  nose. 

The  lesion  commences  in  either  of  two  ways:  (1)  a  cir- 
cumscribed deposit  of  gummatous  material  takes  place 
between  the  buccal  and  nasal  surfaces  of  the  soft  palate;  or 
(2)  there  is  a  diffuse  infiltration  of  the  entire  velum,  its 
mucous  membrane  becoming  reddened  and  its  mobility 
impaired.  Rupture  of  the  abscess  or  ulceration  of  the 
infiltrated  tissues  may  involve  one  or  both  mucous  surfaces, 
thus  causing  partial  or  complete  perforation  of  the  soft 
palate  with  its  concomitant  symptoms  such  as  regurgita- 
tion of  the  food  and  nasal  articulation.  As  the  process  of 
repair  commences,  the  opening  gradually  contracts  until  it  is 
greatly  diminished  in  size,  or,  in  some  cases,  completely 
occluded. 

THE  PHARYNX. 

Erythema,  superficial  ulcers,  and  deep  ulcerations,  result- 
ing from  the  degeneration  of  gummatous  tumors,  may  be 
observed;  mucous  patches  are  extremely  rare  in  this  region. 

The  posterior  portion  of  the  lateral  avails  is  most  frequently 
attacked.  Gummatous  tumors  have  been  seen  upon  the 
vault  of  the  pharynx  and  on  the  upper  part  of  its  posterior 
wall.  The  lesions  encountered  in  this  region  are  similar 
to  those  observed  in  the  mouth,  and  require  about  the  same 
local  and  constitutional  treatment. 
18 


274  SYPHILIS  OF  THE  DIGESTIVE  ORGANS 

THE  ESOPHAGUS. 

Syphilitic  ulceration  of  the  mucous  iiienibrane  of  the  walls 
of  the  esophagus  sometimes  occurs  in  untreated  cases,  and 
as  the  ulcers  heal,  their  cicatrices  contract,  thus  forming 
stricture  of  the  tube,  which,  because  of  the  narrowing, 
interferes  with  deglutition,  and  therefore  with  the  proper 
nourishment  of  the  patient,  who  becomes  emaciated  and 
feeble. 

If  the  diagnosis  is  made  early  enough  and  proper  treat- 
ment instituted,  the  formation  of  a  stricture  can  be  avoided. 

Cases  of  gumma  of  the  esophageal  wall  have  been  reported. 

THE  STOMACH  AND  INTESTINES. 

Accompanying  the  appearance  of  the  early  secondary 
manifestations  there  is  sometimes  seen  functional  disturb- 
ance of  the  digestive  organs,  such  as  loss  of  appetite,  nausea, 
and  vomiting.  This  is  probably  due  to  syphilitic  erythema 
of  the  stomach  and  intestines. 

Ulcerations  of  the  mucous  membrane  of  these  viscera, 
possibly  due  to  degeneration  of  gummatous  deposits,  have 
been  observed  at  postmortem  examinations. 

THE  RECTUM  AND  ANUS. 

Syphilitic  lesions  of  the  anus  and  rectum  may  be  primary, 
secondary,  or  tertiary  in  character. 

The  primary  lesion,  or  chancre,  is  found  in  this  region 
not  infrequently,  and  possesses  the  same  characteristics 
as  in  other  parts  of  the  body. 

Secondary  manifestations  include  macular  or  papular 
eruptions  about  the  anus,  which,  owing  to  moisture  and  the 


THE  LIVER  275 

constant  contuct  of  tlic  ]>}irts,  soon  l)cc;ome  transformed 
into  mucous  patches  or  condylomata.  'J'lic  lesions  may  also 
occur  about  the  anus  in  the  form  of  tubercular  syphilidcs. 
In  the  rectum  itself  the  most  frequent  syphilitic  lesion  is  the 
se(;()n(lary  ulcer.  The  ulcers  may  be  single  or  nnilti[)le; 
they  arc  "punched-out,"  with  sharply  defined,  indurated 
edges,  and,  at  first,  involve  only  the  mucous  membrane  and 
submucosa.  In  their  later  stages  they  extend  deeper,  with 
marked  destruction  of  tissue,  and  give  rise  to  a  foul,  offensive 
and  higlily  infectious  discharge.  The  sacral  lymph  nodes 
are  markedly  enlarged  and  the  wall  of  the  rectum  in  tin; 
neighlwrhood  of  the  ulcers  is  tough  and  indurated.  Healing, 
in  this  stage,  is  very  liable  to  be  followed  by  stricture  of  the 
rectum,  owing  to  the  extensive  formation  of  fibrous  tissue 
which   occurs. 

The  tertiary  manifestations  include  gumma,  which  may 
be  single  or  multiple,  and  a  peculiar  slow,  productive  inflam- 
mation,   with   extensive   connective-tissue   production. 

The  gummata  may  break  down  and  ulcerate,  in  which 
case  stricture  is  liable  to  occur,  and  this  is  even  more  fre- 
quently the  case  after  the  form  of  proliferative  proctitis 
described  above. 

Cases  of  gummatous  infiltration  and  ulceration  have  been 
mistaken  for  carcinoma,  and  the  patient  subjected  to  extir- 
pation of  the  rectum,  a  fact  which  must  not  be  forgotten 
by  the  surgeon  when  examining  these  cases. 

THE  LIVER. 

The  liver  is  invaded  by  syphilis  more  frequently  than  any 
other  abdominal  organ. 

Congestion  of  the  liver  sometimes  occurs  in  the  secondary 


270  SYPHILIS  OF  THE  DIGEST  I VE  ORGANS 

stage  ot"  the  disease,  and  is  usually  associated  with  a  eutaiu'ous 
eruption;  it  may  last  for  from  one  to  sexeral  weeks  in 
untreated  cases. 

The  symptoms  are  icterus,  gastric  disturbances,  and  febrile 
reaction,  the  organ  being  sensitive  on  ])ressure. 

This  condition  is  j)ro])ably  due  to  the  extension  of  a  specific 
catarrh  of  the  intestine  to  the  liver,  by  way  of  the  common 
bile  duct. 

The  tertiary  forms  of  syphilitic  affections  of  the  liver  are: 
amyloid  degeneration,  perihepatitis,  and  hejiatitis,  of  which 
there  are  two  forms,  the  diffuse  and  the  gummatous. 

The  symptoms  of  hepatic  gunmia  are  often  obscure;  the 
organ  may  be  increased  in  size  and  nodules  felt  upon  its 
surface.  Pain  may  })e  present  or  absent.  The  functions 
of  the  organ  are  not  interfered  with  unless  the  tumors  are 
numerous  or  large.  In  severe  cases  there  may  be  icterus, 
gastro-intestinal  disturbance,  and  clay-colored  stools,  flue 
to  obstruction  of  the  gall  ducts  by  pressure  from  the  tumor. 

Without  the  assistance  of  the  Wassermann  reaction  the 
differential  diagnosis  from  carcinoma  may  be  very  difficult, 
even  after  an  exploratory  laparotomy. 

The  diffuse  variety  is  clinically  indistinguishable  from 
other  forms  of  hepatic  cirrhosis. 


THE  SPLEEN. 

In  rare  cases  enlargement  of  the  spleen  occurs  early  in 
the  course  of  sj'philis.  The  swelling  is  quite  rapid,  usually 
painless,  l)ut  may  give  rise  to  a  feeling  of  weight  in  the  left 
hypochondrium.  It  generally  subsides  in  three  or  four 
weeks,   but  may   remain   several   months,   if   treatment  is 


77/ A'   PANCREAS  277 

withheld  or  is  iiiii(l<'(|ii!itr.     it  iii;i\  occur  ;it  ;iiiy  time  (hiriiif^ 
the  secondary  period. 

Gummata  of  tlie  sj^leen  arc  citiier  siiif^lc  or  iiiiilti]jlc,  and 
vary  in  size  from  that  of  a  millet-seed  to  a  walnnt;  they  may 
be  deeply  seated  or  sit  ii;it cd  ii|)()ii  tlic  pcriplicry  of  tli<;  organ. 

THE  PANCREAS. 

Specific  affections  of  the  pancreas  are  very  rare,  bnt  it 
cannot  be  denied  that,  like  the  other  viscera,  it  is  subject  to 
the  diffuse  and  circumscribed  lesions  of  syphilis. 


CHAPTER  XXVI. 
SYPHILIS   OF   THE   RESPIRATORY   ORGANS. 

THE  NOSE. 

The  mucous  membrane  lining  the  nose  may  be  the  seat 
of  erythema,  mucous  patches,  and  ulcerations,  as  can 
be  readily  demonstrated  by  examination  with  the  nasal 
speculum.  The  symptoms  of  these  lesions  resemble  those 
of  ordinary  catarrhal  rhinitis. 

In  the  later  stage  of  syphilis  deeper  ulcerations  may  occur, 
which  originate  in  gummatous  infiltration  of  the  submucous 
tissue,  and  may  finally  involve  the  adjacent  cartilages  and 
bones,  thus  leading  to  serious  deformity  of  the  organ  from 
destruction  of  its  framework  (saddle-nose). 

THE  LARYNX. 

Laryngeal  lesions  are  very  variable  as  regards  their  time 
of  appearance  and  the  severity  of  their  symptoms.  The 
invasion  is  usually  insidious,  and  the  course  chronic  and 
painless. 

The  secondary  or  superficial  lesions  consist  of  erythema, 
mucous  patches,  superficial  ulcerations,  chronic  inflamma- 
tions, and  vegetations. 

Erythema  of  the  larynx  causes  some  huskiness  of  the  voice 
and  slight  catarrh.     It  may  occur  during  the  course  of  the 


THE  LARYNX  279 

early  skin  eruptions,  and  is  either  difluse  or  cirenniscribcfl; 
superficial  erosions  soni(;tiiTies  develo]). 

Sui)eriicial  ulcerations  involve  only  tlie  mucous  incnihrane. 
Their  margins  are  shari)ly  defined,  regular,  and  slightly 
elevated,  and  the  floor  is  covered  by  a  tenacious  secretion. 
They  may  interfere  with  phonation  to  a  more  or  less  marked 
degree. 

Mucous  patches  may  be  situated  upon  any  portion  of 
the  mucous  membrai>e.  If  exposed  to  irritation  during 
respiration  or  phonation  they  become  prominent,  with 
ragged  margins. 

Chronic  inflammation  may  appear  early  or  late  in'^the 
disease.  It  is  a  very  persistent  affection,  and  usually  leads 
to  a  thickening  of  the  mucous  membrane.  Chronic  ulcers 
are  always  associated  with  this  condition. 

Vegetations  may  spring  from  the  margin  of  an  ulcer  or 
from  the  mucous  membrane  itself. 

The  tertiary  lesions  comprise  deep  ulcerations,  gummata, 
inflammation,  and  necrosis  of  the  cartilages. 

Deep  ulcerations  occur,  and  generally  begin,  in  degener- 
ated gummata.  Extensive  regions  may  be  destroyed  in  this 
manner. 

Gummata  of  the  larynx  may  be  either  single  and  large  or 
multiple  and  small. 

The  deposit  sometimes  undergoes  absorption,  but  without 
treatment  it  usually  degenerates,  forming  deep,  ragged 
ulcers,  W'hich  may  attack  the  framework  of  the  larynx  and 
produce  p,ermanent  deformity. 

These  lesions  are  liable  to  cause  an  impediment  to  respira- 
tion, either  from  their  size  or  from  causing  acute  edema 
of  the  larynx. 

Perichondritis  is  usualh'  caused  bv  an  extension  outward 


.280      svrfin.is  OF  THE  hksp/ratory  organs 

of  ail  iiidamniatory  or  iilccratixc  process  troiii  the  imicous 
or  sul)imicoiis  tissue.  The  eartilai;es  themselves  may  be 
nivaded  by  the  process  and  partiall.x  or  totally  destroyed. 

Necrosis  occurs  in  those  cases  in  whicli  tiie  (•artilaf>;es 
are  ossified  and  is  a  very  late  manifestation.  It  follows 
])erichon(lritis. 

THE  TRACHEA  AND  BRONCHI. 

Syphilitic  lesions  of  the  trachea  and  bronchi  are  rare, 
but  may  be  similar  to  those  which  attack  the  larynx. 

Ulcerative  processes,  following  gummatous  infiltration,  are 
the  most  common  and  sometimes  result  in  stricture,  from  the 
contraction  of  their  cicatrices. 

The  principal  symptoms  of  tracheal  syphilis  are  cough, 
purulent  expectoration,  and  dyspnea.  If  stenosis  of  the  tube 
occurs,  its  most  common  seat  is  just  above  the  bifurcation. 


THE    LUNGS. 

Pulmonary  lesions  due  to  syphilis  are  of  rare  occurrence. 
They  include  syphilitic  sclerosis,  or  induration,  and  gummata. 

Syphilitic  sclerosis  aft'ects  a  variable  extent  of  the  middle 
or  lower  lobes  but  rarely  involves  an  entire  lobe;  it  may  be 
disseminated  at  \'arious  points.  The  diseased  portion  of 
lung  becomes  firm,  elastic,  and  furrowed,  while  the  con- 
tained bronchi  are  flattened  and  the  surrounding  pleura 
more  or  less  thickened. 

Gummatous  tumors  may  be  single  or  multiple,  and  resemble 
those  situated  in  other  organs.  They  are  not  at  all  common, 
but  occur  more  frequently  than  syphilitic  induration.    They 


THE  riJcvuA  281 

undergo    {legenerutioii    \vi\\\\    I  lie    ccnln'    oiitwjinl,    lc;i\iiig 
cavities  witJi  wliite,  fibrous  vvulls. 

Ill  some  cases  sy])liilitic  lesions  ol'  the  lungs  cause  no  syiiip- 
toms;  in  others  tJiere  is  more  or  U'ss  (listnr})ance  of  res})ira- 
tiou,  and  in  yet  otJiers  there  are  cougli,  pain,  expectoration, 
and  all  the  symptoms  of  pulmonary  tuberculosis.  The 
temperature  rarely  goes  above  101°  F.  The  diagnosis 
depends  on  the  presence  of  a  positive  Wassermann  reaction 
and  the  absence,  on  repeated  examination,  r)f  tubercle  bacilli 
from  tlie  sputum. 

THE   PLEURA. 

During  the  secondary  stage  of  syphilis  patients  may 
complain  of  pain  in  the  chest,  which  is  associated  with  more 
or  less  rise  of  temperature  and  a  moderate  amount  of  effusion 
into  the  pleural  cavity. 


CHAPTER  XXVII. 
SYPlllLlS  OF  THE  ORGANS  OF  CIRCULATION. 

THE    HEART. 

Tertiary  syphilis  may  attack  the  Jicart  in  citlier  of  two 
ways:  (1)  as  a  chronic  inflammation  (myocarditis),  and  (2) 
as  gummatous  tumors. 

Endocarditis  occurs  about  the  end  of  the  second  year,  and 
is  usually  associated  with  myocarditis;  most  frequently  it 
attacks  the  left  ventricle  at  the  apex  or  base  of  the  organ. 
Gummatous  endocarditis  attacks  any  and  all  parts  of  the 
heart,  giving  rise  to  tumors  of  various  sizes.  Pericarditis 
usually  follows  myocarditis,  and  attacks  either  the  visceral 
layer  or  the  entire  pericardium. 

Gummatous  tumors  of  the  pericardium  are  very  rare,  and 
usually  follow  myocarditis. 

The  symptoms  of  cardiac  syphilis  are  absent  in  many 
cases  and  very  obscure  in  others.  The  action  of  the  heart 
may  become  irregular  and  feeble,  and  the  patient  suffer 
from  palpitation,  dyspnea,  cyanosis,  and  ])ain  o^'cr  the 
precordium. 

The  diagnosis  is  rarely  made  except  by  tlie  disappearance 
of  the  symptoms  after  antisyphilitic  treatment  administered 
for  some  other  manifestation  of  the  disease. 


77/7';   BLOODVIC^HML^  283 

THE   BLOODVESSELS. 

Syphilitic  alTcctioiis  of  the  veins  }iik1  «ii)ill;irics  arc  very 
rarely  encountered.  , 

The  arteries  may  be  attacked  primarily  or  secondarily  to 
specific  disease  of  the  surrounding  tissues.  Primary  lesions 
generally  occur  in  the  small  arteries  of  the  brain.  In  the 
large  arteries  gummatous  foci  sometimes  appear,  which 
may  break  down  and  perforate  the  vessel  wall,  with  resulting 
hemorrhage  into  the  surrounding  tissue  or  body  ca^dties. 

In  affections  of  the  smaller  arteries  the  caliber  of  the  vessel 
is  reduced,  and  sometimes  occluded,  by  a  new,  dense,  cellular 
formation  in  the  internal  coat,  which  resembles  granulation 
tissue,  and  finally  becomes  organized  (endarteritis  obliter- 
ans). This  new  formation  involves  the  entire  circumference 
of  the  vessel,  and  extends  outward  as  well  as  inward,  invad- 
ing both  the  middle  and  external  coats.  It  occurs  in  patches, 
which  are  generally  single;  a  thrombus  may  form  on  the 
patch,  become  organized,  and  thus  obstruct  the  lumen  of 
the  vessel;  or  it  may  become  detached,  with  a  resulting 
embolism. 

In  some  instances  the  changes  in  the  artery  are  xevy  slight, 
the  process  being  limited  to  the  internal  coat;  in  others 
the  vessel  is  thickened,  rigid,  and  nodulated  in  appearance. 

The  disease  most  frequently  affects  the  carotid  and  its 
branches,  especially  the  middle  cerebral;  syphilitic  aortitis 
is  also  quite  frequently  encountered. 

These  lesions  may  occur  as  early  as  the  first  year  or  as 
late  as  the  twentieth,  but,  as  a  rule,  appear  about  the  third 
year  after  infection,  in  untreated  or  improperly  cared-for 
cases. 

As  can  readily  be  seen  from  the  above,  the  symptoms  will 
depend  entirely  on  the  location  of  the  lesions. 


c  H  A  p  T  i:  n  X  X  ^■  1 1 1 . 

SYPIIILTS  OF  THE   (IKNITOrPvIXAUY  OlUiAXS. 

EPIDIDYMITIS. 

Syimiilitic  epididymitis  may  occur  as  early  as  tlic  second 
month  or  as  late  as  the  fifth  year,  but  generally  de\el()ps 
within  the  first  six  months  of  the  disease,  in  insufficiently 
treated  cases. 

It  is  more  commonly  unilateral  and,  as  a  rule,  attacks  the 
globus  major. 

Its  invasion  is  usually  unattended  by  any  symptoms, 
except  occasionally,  when  there  is  a  slight  sense  of  uneasiness 
in  the  part. 

The  lesion  consists  of  a  smooth,  hard,  round,  or  oval 
and  non-painful  tumor,  situated  just  above  the  testicle, 
usually  about  the  size  of  a  pea,  but  in  some  instances  larger. 
It  shows  no  degenerative  tendency  and  cjuickly  disappears 
under  antisyphilitic  treatment.  The  scrotum  remains 
unaffected. 

ORCHITIS. 

Syphilitic  orchitis  is  sometimes  observed  as  early  as  the 
fourth  or  fifth  month,  but  in  the  majority  of  cases  it  is  a 
tertiary  manifestation  and  appears  several  years  after 
infection. 

One  or  both  testicles  may  be  involved,  either  at  the 
same  time  or  con<iecutively. 

The  body  of  the  organ  becomes  increased  in  size,  hard, 


ORcnrns  285 

smooth,  very  heavy,  and  painless,  iuid  tli(;rc  is  uiore  or  less 
hydrocele  of  t.h(>  tunica  vaginalis. 

At  the  l)e<;innin<^  of  the  disease  there  may  he  litth-  ])rojcr- 
tions  n])on  the  surface  of  the  testicle,  due  to  syphilitic 
dej)osits,  which,  as  the  process  continues,  fuse  together, 
forming  a  hard  tumor,  resembling  almost  exactly  the  shape 
of  the  normal  testicle.  In  other  cases  the  surface  of  the 
tumor  is  perfectly  smooth  from  the  beginning. 

The  course  of  this  affection  is  very  slow.  If  untreated,  it 
may  result  in  partial  or  complete  atrophy  of  the  organ,  or 
the  parenchyma  of  the  gland  may  degenerate  into  fibrous, 
cartilaginous,  or  even  osseous  tissue.  As  a  general  rule, 
suppuration  does  not  occur,  although  it  may  occasionally 
follow  the  breaking  down  of  gummatous  deposits. 

The  lesions  may  be  difi'use  or  circumscribed. 

In  the  diffuse  form  the  whole  organ  is  increased  in  size, 
firm,  hard,  and  resistant,  and  unless  treated,  becomes 
atrophied.  There  is  also  frequently  a  certain  amount  of 
hydrocele. 

The  enlargement  is  imiform;  the  outline  of  the  epididymis 
is  often  lost,  although  it  may  appear  as  a  separate  swelling, 
surmounting  the  larger  mass;  the  normal  testicular  sensi- 
tiveness is  decreased  or  lost,  and  the  induration  is  of  a 
peculiar  "woody"  character.  The  organ  feels  peculiarly  and 
characteristically  heavy. 

In  the  circumscribed  form  gummatous  material  is  deposited 
in  masses  through  the  testicle.  These  masses  have  a  ten- 
dency to  undergo  secondary  degeneration  and  softening,  thus 
causing  inflammation  and  ulceration  of  the  surrounding 
tissues,  finally  leading  to  syphilitic  "fungus"  of  the  testicle. 

It  yields  readily  to  treatment,  if  recognized  at  an  early 
period. 


286      SYPHILIS  OF  THE  GEXIW-URINARY  ORGANS 

The  vas  deferens  usually  remains  normal  in  sy])hilitic 
orchitis,  although  it  may  \)c  involved;  this  is  true  also  of 
the  vesiculffi  seminales  and  ]:)r()stato  gland. 

Tlie  chief  conditions  to  be  ditt'erentiated  are  tuberculosis 
and  malignant  growths. 

In  tuberculosis  the  disease  begins  most  often  in  the 
epididymis  instead  of  the  testis  proper;  the  vas  deferens 
is  involved  early  in  the  disease,  and  there  is  frequently  a 
coincident  implication  of  the  prostate  and  seminal  vesicles. 

Abscess  and  sinus  formation  are  much  more  frequent. 

Malignant  growths  are  sometimes  hard  to  difi'erentiate, 
but,  as  a  rule,  the  swelling  is  more  nodular,  its  growth  more 
rapid,  and  there  is  a  marked  tendency  to  cyst  formation. 
Pain  is  also  a  more  prominent  feature. 

The  Wassermann  reaction  is  of  great  value  in  clearing 
up  the  diagnosis. 

The  differentiation  is  important,  as  sypliilitic  testes  have 
not  infrequently  been  removed  by  mistake. 

THE   PENIS. 

Gummatous  deposits  may  occur  in  tlie  penis,  especially 
near  the  coronal  sulcus,  and  are  also  occasionally  found  in 
the  corpora  cavernosa. 

These  syphilitic  deposits  gradually  increase  in  size  without 
giving  rise  to  any  pain,  but  soon  cause  deformity  of  the 
organ,  especially  during  erection,  owing  to  occlusion  of  the 
spaces  of  the  erectile  tissue. 

THE   UTERUS    AND    ADNEXA. 

Syphilitic  affections  of  the  ovaries  resemble  those  of  the 
testes,  but  are  rarely  encountered. 


THE  KIDNKYH  287 

The  symptoms  are  slight  pain  and  increase  in  the  size  of 
the  organs,  with  loss  of  the  sexual  appetite  and  sterility. 

The  Fall()i)iiiii  tubes  are  very  rarely  involved. 

Gummatous  infiltrations  and  tumors  of  tJie  uterus  are 
occasionally  rejoorted . 

Exulcerative  hypertrophy  of  the  cervix  consists  of  an 
enlargement  and  hardening  of  the  os,  which  becomes  con- 
gested and  ulcerated,  the  secretion  from  the  ulcer  Ix'inij; 
contagious,  scanty,  and  mucopurulent  in  character.  This 
lesion  may  occur  at  any  time  after  infection,  and  runs  a 
chronic  course,  but  responds  readily  to  local  and  const iln- 
tional  treatment. 

THE    KIDNEYS. 

In  the  kidneys  of  syphilitic  subjects  the  same  lesions  may 
be  met  with  as  occur  in  the  other  organs,  such  as  interstitial 
nephritis,  to  which  the  transient  albuminuria  met  with  in 
some  patients  is  chargeable,  gummatous  tumors,  and  cica- 
trices, which  latter  result  from  the  preceding  affections. 


CHAPTER   XXIX. 
SYrillLIS  OF  THE   NERVOUS  SYSTEM. 

Syphilitic  affections  of  the  nervous  system  are  of  frequent 
occurrence;  they  may  appear  as  early  as  the  second  month 
or  as  hite  as  the  twentieth  year  after  infection,  and  are  more 
frequent  in  men  than  in  women.  Nervous  phenomena  are 
more  apt  to  occur  in  neurotic  subjects  and  those  addicted 
to  alcohoHc  excesses;  also  in  those  who  have  not  received 
proper  and  sufficient  treatment  in  the  early  stages  of  the 
disease.  Brain-workers,  and  those  who  are  mentally  and 
physically  exhausted,  are  especially  suscei)tible  to  nervous 
manifestations;  as  are  also  those  wlio  have  suffered  from 
sunstroke,  or  antecedent  meningitis.  Arteriosclerosis,  or  any 
other  condition  causing  cerebral  congestion,  also  renders  the 
patient  liable  to  nervous  affections. 

The  Skull  and  Vertebrae. — Lesions  of  the  bones  may  be 
situated  on  the  inner  surface  of  the  skull  or  ^'ertebr8e•,  and, 
by  the  pressure  they  exert,  cause  inflammation  of  the  men- 
inges and  secondary  changes  in  the  brain  or  cord.  These 
lesions  ma>'  be  periostitis,  osteitis,  nodes,  exostoses,  or 
necrosis. 

The  Dura  Mater. — The  dura  mater  is  very  susceptible  to 
syphilitic  imasion.  The  changes  produced  in  it  are  increase 
in  thickness,  roughening  of  its  inner  surface,  and  increased 
vascularity.  It  may  be  affected  alone,  or  the  disease  may 
extend  to  the  inner  surface  of  the  skull  and  the  arachnoid, 


TlIK   AH'J'KiaKS  2S\) 

or  the  dura  mater  may  hv,  secoiidarily  invoked  \)\  professes 
begimiing  in  tJio  ])ia  mater  and  arachnoid. 

The  syphiloma  may  be  diffuse  or  riicuniscriKcd.  Sypliiln- 
mata  of  tlie  S|)inid  dura  mater  reseuihlc  those  ol  the  (cicliiid 
•in  origin  and  course. 

The  Arachnoid  and  Pia  Mater. — An'eclions  of  the  arachnoid 
and  i)ia  mater  consist  ot"  con<i;estion  and  cniargemcnl  of  the 
vessels,  with  inerease  of  coiuieetive  tissue  and  tJiickening. 
Sometimes  gummatous  infiltration  occurs,  giving  rise  to  a 
gummatous  meningitis. 

The  lesion  may  invade  the  dura  mater  and  the  bones  of  the 
skull,  and  is  probably  the  most  frequent  syphilitic  lesion.  It 
occurs  in  })atches,  which  are  sharply  circumscribed  and  either 
single  or  multiple. 

The  Brain  and  Cord. — Affections  of  the  brain  and  cord  are 
nearly  always  secondary  to  lesions  of  the  bones,  meninges, 
or  bloodvessels,  and  consist  of  diffuse  or  circumscribed 
gummatous  deposits. 

The  Arteries. — The  large  arteries,  especially  those  at  the 
base  of  the  brain,  are  more  commonly  attacked  by  syphilis 
than  the  smaller  ones  and  those  of  the  convexity.  The  lesion 
consists  at  first  of  an  infiltrated  condition  of  the  walls  and 
more  or  less  swelling  of  the  endothelium;  later  on,  the  vessels 
become  thickened  and  subject  to  an  obliterating  endarteritis, 
causing  a  diminution  of  caliber,  which  may,  unless  recognized 
and  properly  treated,  go  on  to  complete  occlusion  of  the 
artery.  The  cerebral  tissues  supplied  by  the  affected  vessel 
are  at  first  insufficiently  nourished,  and  finally,  receiving 
no  nourishment  at  all,  undergo  degenerative  changes  from 
total  lack  of  arterial  blood  supply. 

The  lesion,  which  may  attack  one  or  se\eral  vessels, 
either  at  the  same  time  or  successively,  usually  involves  the 
19 


290         sYrniiJS  OF  THE  nervous  system 

entire  circumference  of  the  artery,  and  may  extend  for  an 
inch,  or  even  more,  along  its  length  or  continnity. 

The  Nerves. — The  cerebrospinal  nerves  may  he  in\acled  by 
the  lesions  of  the  meninges,  or  they  may  be  surrounded  by 
gummata  or  compressed  as  they  pass  through  bony  canals. 

Tlie  tliird  i)air,  or  motor  oculi,  are  most  often  affected, 
altiiough  the  first  (olfactory),  second  (optic),  fourth 
(pathetic),  and  sixth  (abducent)  are  sometimes  involved, 
and  tlie  seventh,  or  facial,  quite  rarely. 

There  may  be  a  neuritis  and  perineuritis. 

The  peripheral  ner^'es  are  affected  in  a  similar  manner. 

The  sympathetic  nerves  may  be  invaded  in  either  one  of 
two  ways:  (1)  by  pigmenbiry  or  colloid  degeneration  of  the 
nerve  cells;  and  (2)  by  sclerosis  of  the  connective  tissue, 
causing  atrophy  of  the  nervous  elements. 

Syphilitic  Tumors  of  the  Nervous  System. — Two  forms  of 
syphilitic  tumors  occur  in  the  cranio^•erteb^al  cavity;  they 
are  usually  connected  with  the  cerebrinn,  but  may  be  found  in 
the  medulla,  the  cord,  or  the  cerebellum. 

The  first  form  is  grayish  red  in  color,  highly  vascular,  and 
either  firm  or  soft  in  consistence.  It  consists  of  small,  round 
•  cells  in  a  stroma  of  connective  tissue. 

The  second  form,  which  is  really  a  degenerating  stage  of 
the  first,  is  yellow  in  color  and  hard. 

These  tumors  may  be  single  or  multiple,  and  vary  in  size 
from  that  of  a  pea  to  a  walnut. 

They  occur  chiefly  on  the  under  surface  of  the  brain,  near 
the  Sylvian  fissure,  and,  as  a  rule,  are  peripheral;  but  if 
found  in  the  brain  tissue  itself,  it  will  be  observed  that  they 
have  grown  in  from  the  vascular  membrane. 

Hemiplegia. — Syphilitic  hemiplegia  may  occur  as  early  as 
the  third  month  or  as  late  as  the  twentieth  year  after  infec- 


^YI'lllhl'I'K!   /'J/'/fJ'H'SV  291 

tioii,  and  is  usually  preceded  by  loculized  licaduclic,  vertigo, 
and  convulsions.  Sometimes  there  are  imiscular  sj)Hsms, 
pains,  or  mnnbness  in  the  parts,  which  afterward  become 
paraly/ed. 

The  invasion  may  b(;  eitlier  gradual  or  sudden,  and  usually 
comes  on  when  the  patient  is  engaged  in  some  nuiscular  eflort 
or  is  in  bed  at  night. 

If  the  paralysis  be  partial  it  may  gradually  improve,  or 
even  disappear,  or,  as  improvement  takes  place,  the  opposite 
side   may   be   similarly   affected. 

In  rare  cases  there  is  a  loss  of  both  motion  and  sensation; 
this  may  be  accompanied  by  paralyses  of  various  nerves, 
aphasia,  mydriasis,  optic  neuritis,  and  epilepsy.  Some 
patients  suffer  from  mental  depression,  while  others  are  very 
emotional. 

Syphilitic  epilepsy  may  occur  as  grand  mal  or  petit  mal. 

It  is  a  very  frequent  manifestation  of  cerebral  syphilis, 
and  is  always  preceded  by  severe  headache. 

The  symptoms  of  the  severe  form,  or  grand  mal,  consist  of 
sudden  loss  of  consciousness,  tonic  and  clonic  spasms,  facial 
distortion,  foaming  at  the  mouth,  and  stertorous  respiration ; 
the  aura  and  epileptic  cry  are  not  always  present.  These 
convulsions  generally  occur  at  short  intervals  and  with 
well-marked  regularity;  some  patients  regain  consciousness 
in  a  few  minutes,  while  others  remain  in  a  stupid  condition 
for  hours. 

The  mild  form  begins  with  twitching  of  the  muscles  of  one 
side  of  the  face,  turning  of  the  tongue  to  one  side,  a  tendency 
of  the  subject  to  turn  around,  giddiness,  general  trembling 
or  great  weakness,  or  cramps  in  the  extremities,  loss  of  con- 
sciousness, and  a  convulsion.  The  seizure  may  be  confined 
to  a  single  limb  or  one  side  of  the  body.    Very  often  there 


.292  SYPHILIS  OF   THE  NERVOUS  SYSTEM 

is  no  si)asin;  the  patient  loses  eonseioiisness  and  stares 
vacantly  into  space;  this  condition  lasts  a  few  moments  or 
even  se\eral  minutes.  It"  allowed  to  ^o  on  untreated  the 
petit  inal  attacks  are  liable  to  develoi)  into  the  severer 
form,  t^radually. 

Paraplegia. — The  spinal  cord  is  not  so  frecjuently  attacked 
i)y  syphilis  as  is  the  brain,  but  luetic  aH'ections  of  it  are  not 
uncommon. 

The  causes  of  sj'philitic  paraplegia  are  lesions  of  the 
vertebme,  of  the  spinal  meninges,  and  gummata  which 
press  upon  the  cord. 

The  symptoms  consist  of  a  \arying  amount  of  pain  in  the 
back,  weakness  of  the  lower  extremities,  darting  pains  in  the 
legs,  numbness,  tickling  or  aching  pains  in  the  feet,  with 
hyperesthesia  or  anesthesia.  Loss  of  coordination  is  some- 
times observed.  The  expulsive  force  of  the  bladder  and 
rectum  is  weakened. 

A  patient  may  remain  in  this  condition  for  a  long  time, 
luitil,  unless  properly  treated,  complete  paralysis  of  both 
lower  extremities  finally  comes  on.  General  sensation  may 
remain,  or  be  somewhat  impaired  or  lost. 

Paraplegia  is  a  later  manifestation  of  syi)hilis  than  hemi- 
plegia or  epilepsy,  and  generally  occurs  after  the  sixth  year 
of  the  disease,  but  may  show  itself  much  later. 

Aphasia. — Disturbances  of  speech  frequently  occur  during 
the  course  of  syphilis  of  the  nervous  system. 

There  may  be  hesitation  in  speaking  or  iind)ility  to  remem- 
ber certain  words  in  conversation  and  writing,  or  the  use  of 
inappropriate  words. 

The  affection  ma>'  be  either  continu(nis  or  intermittent 
in  character. 


LOCOMOTOR   ATAXIA  203 

Locomotor  Ataxia.  It  is  now  |)ositi\cly  (IctfrmiiMd  tluit 
locomotor  iitaxiii,  or  lubes  dorsiilis,  is  iii\;iriiil)ly  the  result 
of  juitecedeut  sypliilitie  iiil'cetioii.  The  existence  of  u  posi- 
tive Wassermanii  reaction,  at  some  time  diirin^^  the  course 
of  the  disease,  either  in  the  hlood  or  cerebrosj)in;d  (hiid,  <ir 
both,  together  with  the  discovery  of  tiie  Si)irocliet;i  ])<dlida 
in  the  spinal  cord  of  tabetic  patients,  has  definitely  estab- 
lished this  fact. 

The  condition  })e<2jins  most  frequently  between  the 
thirtieth  and  fortieth  years,  although  it  may  be  found 
earlier,  or  even  in  old  age.  Men  are  far  more  frequently' 
affected  than  women.  It  is  probable  that  fatigue  and  over- 
exertion, both  physical  and  mental,  are  accessory  causes. 

The  principal  lesions  in  a  developed  case  consist  of 
thickening  of  the  pia  and  arachnoid,  combined  with  sclerosis 
of  the  posterior  columns  of  the  cord  (cohmins  of  Goll  and 
Burdach),  usually  in  the  lumbar  region,  but  occasionally, 
also,  in  the  cervical.  In  the  early  stages  this  sclerosis  is 
found  principally  in  the  middle  third  of  the  posterior  columns, 
but  in  advanced  cases  the  greater  part  of  the  columns  may 
be  involved,  with  the  exception  of  the  endogenous  fibers. 
There  is  usually  a  more  or  less  marked  lymphocytosis  of 
the  cerebrospinal  fluid. 

The  disease  may  remain  stationary  for  years  after  the 
first  appearance  of  symptoms,  and  then  suddenly  recur, 
or  it  may  progress  steadily  and  rapidly  from  the  ^•ery 
beginning.     Periods  of  remission  are  not  infrequent. 

The  most  prominent  and  characteristic  symptoms  of  the 
disease  are: 

"Lightning"  pains  in  the  extremities:  paroxysmal  and 
usually  momentary,  and  often  associated  with  tenderness, 


294  SYPHILIS  OF  THE  NERVOUS  SYSTEM 

cither  svii)crficial  or  deep,  so  that  they  may  he  iiiistiiken 
for  rheiinuitisin  or  sciatica. 

Ataxia:  due  to  loss  of  tlie  muscle,  tendon  and  joint  senses, 
which  results  in  incoordination  of  movement  and  overaction 
of  the  muscles. 

Loss  of  the  knee-  and  ankle-jerks. 

Inability  to  stand  with  the  feet  toejetluT  and  the  eyes 
c-losed — Romberg's  sign. 

The  Argyll-Robertson  pii])!!,  wliich  reacts  to  light  but  not 
to  accommodation. 

Inability  to  stop  sudtlenly  and  turn  around  witliout 
staggering. 

Gastric  crises,  sorcalled;  and  various  genito-urinary  dis- 
orders, such  as  slowing  of  the  urinary  stream,  difficulty  in 
starting  and  stopping  urination,  retention  of  urine,  residual 
urine,  cystitis,  with  stone  formation,  and  loss  of  sexual 
power. 

Less  frecjuently  we  may  find  loss  of  the  touch  or  pain 
senses;  "girdle"  pains  about  the  epigastrium,  which  may 
be  mistaken  for  renal  colic  or  intercostal  neuralgia;  painless 
perforating  ulcer  of  the  foot;  or  the  so-called  Charcot 
joints,  which  occur  most  frequently  in  the  knee  or  ankle 
and  are  characterized  by  a  painless  enlargement  of  the 
bones  of  the  articulation,  with  intra-articular  efi'usion,  hard, 
periarticular  edema,  erosion  of  the  cartilages  and  the  forma- 
tion of  osteojjhytes  within  the  joint,  with  consequent  grating 
on  motion,   and  finally  subluxation. 

General  Paralysis  (also  known  as  general  paresis). — 
This  afi'ection  is  manifested  by  such  symptoms  as  cerebral 
excitement,  gayness  of  spirits  alternating  with  depression, 
together  with  delirium  or  even  mania.  The  motor  disturb- 
ances consist  of  uncertain  movements  without  paralysis, 


(IKNh'h'A/.   I'AUA  LYSIS  295 

trenil)lii]g  of  tlic  Iiaiids,  hesitating  sjjccch  and  staggering 
gait,  Iicadachc,  dizziness,  and  inipairmtsnt  f)f  sight  and  hear- 
ing, with  epileptit'onn  convulsions. 

These  symptoms  do  not  occur  at  the  same  time  or  in  a 
regular  manner,  hut  ajjpear  at  odd  intervals. 

From  the  foregoing  description  of  the  lesions  of  syphilis 
as  it  affects  the  nervous  system  it  is  easy  to  see  that  the 
symptoms  depend  entirely  on  the  structures  involved,  and 
that  they  may  shift  and  vary  in  a  most  bewildering  manner. 

The  diagnosis  must  often  be  made  almost  wholly  on  a 
history  of  infection  by  the  s])irochete  and  on  the  presence  of 
the  Wassermann  reaction  in  the  blood  or  spinal  fluid  or  both 


CHAPTER  XXX. 
SYPHILIS  OF  THE  MUSCLES. 

MYOSITIS. 

There  are  three  forms  of  syphilitic  all'ections  of  the 
muscles:  (1)  the  irritative  or  hyperemic;  (2)  the  chronic 
infiltrative;  (3)   the  gummatous. 

Irritative  myositis  usually  occurs  in  the  early  stage  of 
syphilis,  and  is  associated  with  pain  and  soreness  in  the 
muscles,  but  leaves  no  permanent  traces  of  its  existence. 

The  chronic  infiltrative  form  consists  of  the  develop- 
ment of  connective  tissue  in  the  interfihrillar  spaces,  which 
eventually  hardens,  resulting  in  atrophy  and  destruction  of 
the  muscle.  Any  muscle  may  be  attacked,  but  the  flexors 
of  the  upper  extremity,  and  especially  the  biceps,  are  most 
frequently  invaded. 

The  muscle  gradually  shortens  without  causing  any  pain; 
the  patient  first  notices  that  he  is  unable  fully  to  extend  the 
limb,  but  no  change  is  detected  on  palpation. 

Its  course  is  chronic,  lasting  for  several  months  or  years 
in  untreated  cases. 

Gummatous  tumors  consist  of  circumscribed  deposits  of 
gummatous  material.  They  are  usually  found  in  the  larger 
muscles,  such  as  the  trapezius,  the  gluteus  maximus,  the 
sternomastoid,  the  vastus  exteriuis,  the  pectoralis  major, 
and  the  walls  of  the  heart.    Gummata  of  the  tongue,  palate, 


77//';   ^11 K  AT  US  OF    Till':    TENDONS  297 

or  pharynx  may  ()ri<;iiia1c  in  tlic  iniisc\ilar  tissue  and  sccoiul- 
iirily  involve  tlic  inucons  nicnihranc.  'I'licy  must  he  (lin'crcn- 
tiated   Itoui   mali^-nant   ,i,^ro\vtlis,   or   even   tulxTculosis. 

Gummata  grow  slo\vl\-  and  witliont  inllannnation;  tlicy 
vary  in  shape  and  size,  cause  no  pain,  hut,  if  large,  uiterfere 
with  motion;  they  occur  late  in  the  disease  and  are  accom- 
panied   hy    other   syphilitic   manifestations. 

As  a  general  rule,  they  do  not  suppurate,  l)ut  may  become 
indurated  and  even  be  converted  into  cartilage  or  bone,  thus 
accounting  for  the  osseous  masses,  which  are  sometimes 
found  in  the  muscles  of  old  syphilitics. 


THE  SHEATHS  OF  THE  TENDONS,  THE  TENDONS, 
THE  APONEUROSES,  AND  THE  BURS^E. 

Dorsal  hygromata  are  firm,  elastic,  fluctuating  tumors, 
which  occur  on  the  backs  of  the  hands;  they  are  triangular 
in  shape,  with  their  bases  tow^ard  the  fingers. 

The  lesion  consists  of  a  diffuse  deposit  of  syphilitic  material, 
with  hyperemia  of  the  sheaths  and  serous  efTusion. 

They  cause  trifling  pain,  unless  very  large,  when  the 
skin  may  become  tense,  inflamed,  and  painful;  they  grow 
rapidly.  They  may  appear  in  the  early  years  of  the  disease 
in  untreated  cases. 

The  tendons  of  the  ankle  and  foot  may  be  similarly 
-affected. 

Gummatous  tumors  are  sometimes  found  in  the  tendons, 
especially  the  larger  ones,  near  their  points  of  insertion  and 
thicker  portions.  They  are  non-painful  and  may  remain 
indolent  for  quite  a  time,  then  break  down  and  form  ulcers. 

Tumors  of  the  aponeuroses  are  more  diffuse  than  those  of 


298  SYPHILIS  OF  THE  MUSCLES 

the  tendons;  their  course  is  similar,  l)ut  they  are  not  so 
\\:\\)\c  to  degenerate. 

As  a  rule,  they  attack  the  firm,  dense  fascia  of  the  extrem- 
ities, especially  the  fascia  lata. 

The  Bursa :  In  the  secondary  stage  of  syphilis  there  may 
be  a  congestiou  of,  and  a  serous  effusion  into,  the  bursa?, 
especially  in  those  most  exposed  to  trauma. 

In  the  tertiary  stage  also  the  bursae  may  be  attacked, 
especially  the  prepatellar  l)ursa. 

The  lesion  consists  of  a  gummatous  infiltration  with 
connective-tissue  formation.  It  begins  painlessly,  as  a  firm, 
hard,  or  elastic  movable  tumor  beneath  the  skin;  it  may 
remain  in  this  condition,  or  acute  inflammatory  symptoms 
may  set  in,  causing  ulceration  of  the  overlying  integument, 
owmg  to  the  occurrence  of  a  "mixed"  infection. 

Syphilitic  dactylitis  consists  of  a  gummatous  deposit  in  the 
subcutaneous  connective  tissue  of  the  fingers  or  toes  and  an 
infiltration  and  inflammation  of  their  bones. 

It  belongs  to  the  tertiary  period  of  the  disease  and  has 
two  varieties. 

In  the  first  variety  the  subcutaneous  connective  tissue 
and  fibrous  structures  of  the  joints  arc  involved. 

In  the  second  variety  the  process  begins  in  the  bones  and 
periosteum,  attacking  the  jomts  secondarily. 

In  the  first  variety  the  lesion  comes  on  slowly,  and  the 
patient's  attention  is  first  attracted  by  the  enlargement  of 
the  finger  or  toe,  which  increases  in  size  and  becomes  harder, . 
The  toes  are  generally  affected  in  their  entire  length;  but 
when  a  finger  is  attacked  the  lesion  is  usually  limited  to  a 
single  phalanx,  although  the  whole  member  may  be  included 
(Fig.  126). 

The  finger  or  toe  becomes  red  in  color,  resistant  and  tense; 


THE  SHEATH,'^  OF   THE    TENDONS 


200 


the  swelling  is  most  iiiiirkcd  on  tlic  dorsjil  aspoct,  jmkI  ends 
al)nii)tly  nt  tin;  inctaciirpopliiilaiij^cal  iirticiihilion ;  it  coiik-s 
on  slowly,  uiid  iiuty  or  jiiii,y  jiot  Ix;  ])uiiil'iil. 

Symptoms  of  joint-implication  appear  vvitliiii  a  few  weeks; 
flexion  is  impaired  by  the  swelling;  and  if  the  condition 
be  left  untreated,  the  joint  finally  becomes  abnormally 
mobile;  sometimes  there  are  hydrarthrosis  and  crepitation 


Fig.  126.— Dactylitis.      (Taylor.) 


between  the  articular  surfaces.  This  process  may  be 
limited  to  one  or  several  members,  and  is  a  late  manifes- 
tation of  the  disease. 

The  second  form  is  limited  to  the  bone,  and  is  due  to  a 
specific  periostitis  or  osteomyelitis.  Its  course  is  either 
rapid,  slow,  or  intermittent.  In  the  majority  of  cases  the 
whole  bone  is  involved,  but  the  disease  may  be  limited  to 
the  extremities  of  two  opposing  phalanges.     The  proximal 


300  SYPHILIS  OF   THE  MUSCLES 

])hal;in\  is  iiioix'  (•(tiiiinoiily  inxoKcd  than  llic  distal  one,  and 
the  Hnu'crs  are  nu)re  t'reciiUMitly  attacked  than  the  toes. 

TUv  process  may  attVct  several  i)lialan<;es  or  finji;ers.  The 
metacarpal  and  metatarsal  hones  can  he  attacked  at  the 
same  time,  or  separately,  hut  the  metacarpal  hones  of  the 
thumb  and  index-finger  are  most  frequently  involved. 

The  integument  is  but  little  affected,  unless  the  swelling 
is  eonsideral)le,  when  it  becomes  tense  and  thin;  in  some 
cases  ulceration  takes  j)lace,  the  inflanunatorx  focus  always 
being  on  the  side  of  the  finger. 

Necrosis  of  the  bone  may  occur,  hut,  as  a  rule,  resolution 
of  the  osseous  swelling  is  the  result.  Bony  crepitation  may 
often  be  detected,  owing  to  erosion  of  the  articular  cartilages. 

Effusion  into  the  joint  sometimes  occurs,  hut  is  not  serious, 
as  the  fluid  is  usually  absorbed.  The  mobility  of  the  articu- 
lation may  be  impaired  or  rendered  too  free. 

The  shaft  of  the  l)one  is  either  shortened  or  slightly 
elongated,  but  ordinarily  the  deformity  is  not  marked. 

Pain  is  very  slight  or  entirely  absent. 


CHAPTER   XXXI. 

SYPHILIS  OF  THE  HONES,  ('AI(TJLA(;ES,  AM) 
JOINTS. 

Osseous  lesions  may  occur  in  tl)c  curly  months  (;f  the 
disease,   but  are  usually  late  manifestations. 

PRECOCIOUS  OSSEOUS  AFFECTIONS. 

The  hones  of  the  cranium,  the  ribs,  the  sternum,  the 
clavicle,  and  the  tibife  are  the  most  liable  to  be  affected. 
Of  the  skull,  the  frontal  and  parietal  bones  are  the  ones 
usually  attacked. 

The  nodes  or  swellings  vary  in  size  from  half  an  inch  to  an 
inch  and  a  half  in  diameter,  and  may  be  half  an  inch  in 
height;  they  are  single  or  multiple,  round,  smooth,  and  hard. 
Similar  lesions  are  liable  to  form  on  the  inner  surface  of  the 
cranium  and  give  rise  to  cerebral  symptoms. 

The  clavicle  is  generally  attacked  at  its  sternal  extremity, 
the  articulation  being  involved  in  some  instances. 

The  upper  third  of  the  sternum  is  more  frequently  affected 
than  the  lower;  the  lesion  may  attack  its  borders  and  costal 
cartilages,  and  in  this  way  set  up  a  localized  pleurisy.  In 
severe  cases  the  ribs  are  also  invaded.  Nodes  are  usually 
situated  upon  the  subcutaneous  surface  of  the  tibia.  The 
radius  and  ulna  may  be  attacked,  generally  near  the  joints, 
the  wrist  more  frequently  than  the  elbow. 


302     SYPHILIS  OF   THE  BONES,   CARTILAGES,  JOINTS 

These  tumors  grow  very  rai)i(ll\ ,  and  ari'  always  accom- 
l)anie(l  by  pain  which  is  worse  at  night. 

The  lesion  is  due  to  hyperemia  of  the  periosteum  and  new 
fibrous  tissue  formation.  The  nodes  rarely  break  down  into 
ulcers,  but  tend  rather  to  spontaneous  iuNolution.  They 
yield  readily  to  treatment,  or,  if  left  alone,  are  converted 
into  bonv  masses. 


LATE  OSSEOUS  LESIONS. 

These  lesions  do  not  necessarily  occur  in  c\ery  case  of 
syphilis.  They  may  appear  with  the  late  secondary 
lesions  or  when  every  other  trace  of  the  disease  has  dis- 
appeared. 

Osteoperiostitis. — In  this  aifection  the  lesion  consists  of 
an  increased  ^•ascularity  of  the  periosteum  and  the  under- 
lying bone  with  an  effusion  and  infiltration  of  either  a  fluid 
or  gelatinous  substance. 

Any  of  the  bones  may  be  affected,  but  especially  the  tibia 
(Fig.  127),  the  ulna  fFig.  128),  the  clavicle,  the  sternum,  and 
the  cranial  bones. 

The  process  causes  soft  tumors  of  variable  size,  gradually 
shading  into  the  surrounding  tissue,  attached  to  the  bone, 
but  not  to  the  skin;  sensitive  on  pressure  and  ])ainful, 
especially  *at  night.    Such  tumors  are  called  nodes. 

Under  appropriate  treatment  these  nodes  undergo  reso- 
lution; otherwise  the  skin  becomes  red,  thin,  and  adherent 
to  the  tumor,  which  breaks  down  into  an  ulcer;  this  results 
in  superficial  necrosis  with  an  adherent  cicatrix. 

In  other  cases  the  effusion  is  transformed  into  bony  tissue, 
constituting  an  exostosis  which,  being  movableupon  the 


LATE  OI^SEOU!^  LEGIONS 


503 


Ih)ti('  })('iie}itli,  is  ciillcd  an  cpipliVHary  exostosis;  tliis  form 
is  duo  to  ])criostitis,  and  sucli  exostoses  are  gerienilly  s?ri;dl 
and  thin. 


Fig.  127. — Osteoperiostitis  of  tibia.     (Bellevue  Hospital.) 

In  other  cases  syphihtic  exostosis  is  the  result  of  osteitis, 
which  results  in  hypertrophy  of  the  bone;  this  form  is  called 


Fig.  128.— Periostitis  of  ulna.     (Belle^^e  Hosintal. 


parenchymatous  exostosis;   the  new  formation  may  be  made 
up  of  either  compact  or  cancellated  tissue. 

Exostoses  mav  be  situated  on  the  inner  surfaces  of  the 


304     SVrUIUS  OF   THE   BONES,   CARTI LACKS,   JOISTS 

craiii;il  hoiu-s  and  ii;i\i'  rise  to  \"cry  serious  (.•('irl)ral  syni])- 
toms.  The  frontal  bone  is  most  frequently  atfeeted  in  this 
manner.  In  rare  instances  exostoses  are  found  in  the 
vertebra",  sometimes  external  and  sometimes  within  tJie 
spinal  canal. 

Osteomyelitis. — The  de])osit  of  syphilitic  material  gener- 
ally takes  place  in  the  medullary  canal  of  the  long  hones,  but 
may  occur  in  the  periosteum  or  e\-en  in  the  substance  of  the 
bone  itself. 

The  bones  of  the  liead  are  also  liable  to  be  affected,  the 
syphilitic  deposit  occupying  the  diploe,  thus  separating 
the  internal  and  external  plates  of  the  skull,  and  leading 
to  caries  or  necrosis,  and  frequently  to  perforation,  either 
internally  or  externally. 

Necrosis  of  the  Maxillary  Bones. — This  manifestation  of 
the  disease  is  most  frequently  seen  in  the  hard  palate  and 
the  alveolar  process  of  the  superior  maxillary  bones. 

Wlien  the  hard  palate  is  affected,  an  abscess  forms  on  the 
roof  of  the  mouth  near  the  median  line,  which  finally  ruj)- 
tures  and  reveals  exposed  bone.  x\fter  separation  of  the 
sequestrum  an  opening  is  left  between  the  nose  and  the 
mouth  which  greatly  interferes  with  articulation  and  deglu- 
tition, but  which  in  time  decreases  in  size  quite  markedly. 

Necrosis  of  the  alveolar  process  occurs  in  the  upper  jaw 
near  the  central  incisors,  and  as  the  disease  extends  the 
teeth  loosen  and  fall  out. 

THE    JOINTS. 

The  joints  may  be  inxohed  during  the  secondary  and 
tertiary  stages. 

Arthralgia. — Pain  in  the  joints  is  frequently  an  early  mani- 
festation. 


77//';  JOINTS  '.M)') 

'^I'lic  lesion  is  ;i  spccilic  iii(l;iiiiiii;il  ion  ol'  the  -,yiio\i;il  iiicm- 
braues  and  fibrous  tissues.  Tiie  skin  remains  noinuil  in  all 
respects  and  tliere  is  no  efl'usion  into  tJu;  joint;  tlic  only 
synii)tonis  l)ein<]!;  |)ain,  with  sometimes  slif^lit  stifTness  of  tlie 
articulation.  Tlie  j)iiin,  wliicli  \iirics  ^rciitly,  <i;cner;ill> 
becomes  worse  at  nif^iit. 

Any  of  tlie  joints  may  be  attacked,  but  "generally  the  larger 
ones,  usually  the  knee. 

In  some  cases  the  cartilages  are  in\aded,  gi\ing  rise  to 
crepitation. 

Synovitis. — There  are  two  varieties  of  syphilitic  synovitis; 
the  ftrst  is  a  chronic  effusion  into  the  joints,  without  change 
in  its  structures;  the  second  consists  of  effusion  witJi  thick- 
ening of  the  synovial  membrane. 

The  first  variety  occurs  in  the  early  stage.  The  affection 
begins  slowly  and  painlessly  and  consists  of  an  effusion  and 
some  stiffness  of  the  articulation.  The  integument  is  not 
involved.  The  effusion  may  be  slight  or  copious,  and,  in 
properly  treated  cases,  is  rai)idly  absorbed,  while  in  neglected 
ones  it  becomes  chronic  and  very  persistent.  Suppuration 
or  destruction  of  the  joint  does  not  occur. 

During  this  process  firm  pressure  may  elicit  some  pain, 
otherwise  there  is  none. 

The  second  variety  occurs  late  in  the  secondary  and  during 
the  tertiary  stage.  The  affected  joint  becomes  slightly 
painful,  enlarged,  and  its  motion  impaired.  Tlie  effusion 
takes  place  slowly  and  is  accompanied  by  thickening  of  the 
synovial  membrane  and  fibrous  tissue. 

The  lesion  is  due  to  gummatous  infiltration  into  the  syno- 
^•ial  membrane.  In  some  cases  the  cartilages  become  more 
or  less  eroded,  thus  giving  rise  to  crepitation.  There  is  but 
little  tendency  to  complete  ankylosis. 

The  knee-joint  is  the  one  most  frequently  affected. 
20 


CHAPTER   XXXII. 
SYPHILIS  OF  THE  EYE. 

The  bones  of  the  orbit  may  be  attacked  by  either  periostitis, 
caries,  or  necrosis,  and  present  the  same  general  symptoms 
as  do  simihir  lesions  in  the  other  bones. 

The  infianimatory  process  may  extend  from  the  diseased 
bones  to  the  contents  of  the  orl)it,  causing  a  cellulitis,  ifdiich, 
if  untreated,  is  liable  to  result  in  abscess  and  partial  or  com- 
plete destruction  of  the  eye. 

These  lesions  usually  attack  the  orbital  plate  of  the  frontal 
and  lacrimal  bones. 

Syphilitic  nodes  can  form  upon  any  part  of  the  walls  of 
the  orbit  and,  if  deeply  situated,  cause  protrusion  of  the 
eye,  with  more  or  less  interference  of  vision. 

Affections  of  the  lacrimal  passages  may  occur  at  any 
period  of  the  disease. 

In  some  cases  they  are  limited  to  the  mucous  membrane 
and  submucous  tissue  and  consist  of  catarrhal  inflammation, 
with  edema  and  ulceration.  In  the  majority  of  cases  the 
process  begins  in  the  bones  or  periosteum  and  involves  the 
mucous  membrane  secondarily. 

As  the  lacrimal  passages  become  impervious,  the  tears 
collect  upon  the  conjunctiva  and  flow  over  the  face;  puru- 
lent matter  forms  in  the  lacrimal  sac  and  regurgitates, 
causing  conjuncti\itis  and  inflammation  of  the  puncta 
lacrimal  is.  If  the  i)rocess  be  very  severe,  an  abscess  may 
form  in  the  lacrimal  sac. 


TREATMENT  ^-|07 

lk;si(lcs  the  thorougli  constitiitioiiiil  treatment  to  \hi  <le- 
scribed  in  ('J);ii)tcr  XX XIV,  the  nuijority  of  cases  rcfiiiirc 
local  measures.  A])|)Hcatioiis  of  50  per  cent,  merciiriiil  oint- 
ment sliould  be  made,  and  ev(;n  the  following  operative 
measure  resorted  to: 

One  or  l)otli  canaliculi  arc  incised  an  far  as  the  caruncle, 
and  dilated  with  a  Bowman  probe;  this  procedure  affords 
great  relief  by  making  a  free  communication  between  the 
sac  and  the  conjunctiva,  and  also  by  giving  an  outlet  to  pus 
or  any  material  that  has  formed  in  the  sac.  If  there  be  an 
obstruction  in  the  nasal  passages,  due  to  edema  of  the  mucous 
membrane,  a  probe  should  be  passed  every  few  days  and  left 
in  situ  for  several  minutes,  thus  restoring  the  original  caliber 
of  the  canal. 

The  lacrimal  gland  may  occasionally  become  involved. 

The  gland  becomes  swollen,  pushing  forward  the  upper 
lid,  which,  in  turn,  becomes  red  and  inflamed. 

Aflfections  of  the  eyelids  are  not  at  all  common;  they  are 
divided  into  eruptions,  ulcerations,  and  infiltrations. 

Eruptions  may  occur  upon  either  the  external  or  the 
internal  surface  of  the  lid,  in  the  form  of  papules  or  pustules. 

The  initial  lesion  or  chancre  may  be  situated  upon  any 
part  of  either  surface  of  the  lid,  but  most  frequently  occurs 
at  its  free  margin. 

Beginning  as  a  papular  or  superficial  ulcer,  it  is  soon  sur- 
rounded by  well-marked  induration,  with  enlargement  of  the 
preauricular  glands. 

In  the  secondary  period  lesions  of  the  lids  occur  as  small, 
elevated,  circumscribed  spots  of  a  grayish-red,  yellow,  or 
copper  color. 

IMucous  patches  are  sometimes  fomid  upon  the  palpebral 
conjunctiva  and  resemble  those  situated  elsewhere. 


308  SYPHILIS  OF   THE  EYE 

Ulcerations  of  the  eyelid  during  this  period  generally  eoin- 
mence  as  guininatous  tumors  or  submucous  infiltrations. 
Tliey  cause  great  destruction  of  the  tissues  and  are  generally 
situated  upon  the  border  of  the  lid. 

Infiltrations  between  the  cartilages  and  the  integument  do 
not  always  ulcerate,  but  may  remain  as  nodules,  which  dis- 
appear under  proper  treatment. 

The  tarsal  cartilages  may  become  inilamed  and  thickened, 
causing  edema  of  the  lid,  with  or  without  redness  of  the 
integument. 

The  att'eetion  is  \er\-  chronic  and  may  result  in  loss  of 
elasticity  of  tlie  cartilage. 

The  tendons  and  fascite  of  the  nniscles  of  the  eye  may  also 
be  invohed  in  the  general  specific  inflammation,  which  is  apt 
to  lead  to  abscess  formation  and  consequent  destruction  of 
the  organ. 

The  ocular  conjunctiva  is  rarely  afl'ectetl  by  syphilitic 
lesions  l)ut  may  be  the  seat  of  tubercles  and  gmnmatous 
tumors,  and  infiltrations.  Cases  of  papules  have  been 
observed  coincidently  with  a  general  eruption;  the  initial 
lesion  is  sometimes  situated  here. 

Secondary  ulceration  may  occur  near  the  margin  of  the 
cornea;  beginning  as  red,  elevated  s])ots,  which  soon  ulcer- 
ate, and  are  liable  to  extend  to  the  cornea. 

Syphilitic  ulceration  of  the  cornea  is  a  not  unconunon 
manifestation.  When  the  inflammation  occurs  it  is  usually 
in  the  substance  of  the  cornea,  and  is  designated  as  paren- 
chymatous keratitis,  of  which  there  are  two  forms:  the 
diffuse  and  the  punctate. 

Diffuse  keratitis  is  generally  accompanied  by  a  \arying 
amount  of  pericorneal  injection  and  slight  grayish  opacity 
of  the  cornea,  which  after  a  time  gives  it  the  api)earance 


TRKATMKNr  309 

ol'  ,t;'r()iiii(l-ji;liiss.  As  u  rule,  then;  is  \\u\  iniicli  pnin  or 
j)li()t(>])li()l)i;i  iit  first,  l)iit  these  syiiii)t()ins  <z;r;i(lii;ill\  increase 
ill   iiiteiisity  and  are  ae('<)in])aiiie(l   by  laeriiiialioii. 

Dill'use  keratitis  is  (lie  I'onii  i^-eiierallx-  ohserxcd  in  younj; 
children  and  is  almost  always  due  to  hereditary  syphilid. 

Punctate  Keratitis:  The  opacity  occurs  in  sharply  limited 
spots  or  points,  whi(;h,  as  a  rule,  do  not  coalesce. 

The  lesion  is  gray  or  yellow  in  color  and  deeply  seated. 

Affections  of  the  sclerotic  coat  are  divided  into  episcleritis 
and  parenchymatous  scleritis. 

Episcleritis  generally  begins  as  a  hyperemic  spot  near  the 
margin  of  the  cornea,  which,  as  the  inflammation  continues, 
becomes  violet  or  purple  in  color.  The  conjunctiva  is  seldom 
involved,  and  then  to  a  limited  extent  only.  Any  part  of 
the  cornea  can  he  affected,  and  several  spots  may  form  at  the 
same  time  and  merge  into  each  other. 

There  is  usually  but  little  pain,  photophobia,  or  lacrima- 
tion  with  this  process,  which  may,  however,  in  some  cases 
invade  the  cornea,  the  iris,  or  the  ciliary  body. 

Parenchymatous  scleritis  is  a  very  rare  affection.  As  a 
rule,  it  commences  by  a  zone  of  injection  around  the  cornea, 
which  is  at  first  pink  in  color,  but  eventually  becomes 
purplish.  This  pinkish  zone  gradually  extends  backward, 
covering  entirely  the  anterior  portion  of  the  ball.  This 
affection  may  ijun  a  chronic,  painless  course,  or  cause  photo- 
phobia, severe  pain,  and  lacrimation. 

The  iris  may  or  may  not  be  implicated. 

The  sclerotic  coat  is  sometimes  the  seat  of  gummatous 
infiltration. 

Syphilitic  iritis  is  one  of  the  most  serious  affections  of  the 
eye,  and  should  be  recognized  early  in  order  that  proper 
treatment  be  employed. 


310  SYPHILIS  OF  THE  EYE 

It  usually  ai)i)iMrs  diiriiii;'  the  secondary  period,  hut  may 
occur  nuicli  later. 

'J'here  arc  three  varieties  of  inflaniniation  of  tlie  iris: 
(1)  simple  or  plastic  iritis;  (2)  serous  iritis;  and  (3)  paren- 
chymatous or  suppurative  iritis. 

Simple  or  plastic  iritis  is  characterized  by  congestion  of 
tlie  iris,  with  the  production  of  an  exudation  from  it,  and  in 
some  cases  by  an  increase  of  the  connective  tissue.  As  a  rule, 
there  is  injection  of  the  conjunctival  and  sclerotic  vessels. 
The  color  of  the  iris  is  changed,  its  surface  is  covered  by  a 
thin  layer  of  fibrin,  and  on  exposure  to  light  it  reacts  slowly 
or  not  .at  all.  The  pupil  may  become  irregular  in  shape, 
owing  to  the  adhesions  between  it  and  the  capsule  of  the 
lens,  or  to  the  exudations  into  its  substance. 

Serous  Iritis:  In  this  affection  the  exudation  is  serous  in 
character,  and  is  due  to  excessive  secretion  of  turbid  aqueous 
humor,  which  generally  produces  an  increased  intra-ocular 
tension;  this  causes  deepening  of  the  anterior  chamber  and 
dilatation  of  the  pupil  from  pressure.  Circumcorneal  injec- 
tion may  be  absent  or  present.  Adhesions  between  the  lens 
and  the  iris  are  very  rare  in  this  form. 

Parenchymatous  or  Suppurative  Iritis:  In  this  form  of 
iritis  there  is  inflammation  in  the  stroma  of  the  iris,  causing 
edema  of  the  membrane  and  increase  in  its  cellular  tissue 
elements.  Elevations,  also  called  tubercles,  or  condylomata, 
occur  upon  the  surface  of  the  iris,  and  in  composition  are 
identical  with  gummy  tumors.  The  vessels  of  the  membrane 
are  congested  from  retardation  of  their  circulation.  Adhe- 
sions between  the  margin  of  the  pupil  and  the  lens  are  very 
common.  Pus  is  produced  rapidly  and  abundantly  in  the 
anterior  chamber. 

Pain  and  photophobia  may  be  very  severe,  or  in  .some 


TJa<:ATMi<:NT  •'' ' 

cases  oiitiroly  wiiiilin^-;    \isi()ii  is  alwiiys  more  or  l<-,.  mlcr- 
fcrcd  with. 

If  the  affection  })e  early  and  properly  treated,  the  eye 
returns  to  its  normal  condition;  ))ut  in  cases  that  are  nc;^- 
lected,  permanent  adhesions  form,  which  impede  the  nu»tion 
of  the  iris. 

The  patient  should  be  kept  in  a  shaded  but  not  darkened 
room,  going  out,  if  at  all,  in  the  evening,  to  avoid  the  glare. 

The  constitutioiual  treatment  to  be  described  later  slujuid 
be  begun  immediately. 

To  prevent  the  formation  of  adhesions  between  the  iris  and 
the  capsule  of  the  lens,  the  pupil  must  be  kept  constantly 
dilated  with  a  solution  of  sulphate  of  atropin  (2  grains  to 
the  ounce  of  distilled  water),  this  being  dropped  in  two  or 
three  times  daily;  it  also  reheves  the  pain  and  irritation. 
If  the  iris  does  not  yield  to  the  use  of  atropin,  mercurial 
inunctions  may  be  made  over  the  brow  and  temple.  But  if 
these  measures,  combined  with  vigorous  constitutional 
treatment,  fail  to  relieve,  evacuation  of  the  contents  of  the 
anterior  chamber  by  paracentesis  cornese  may  have  to  be 
resorted  to. 

For  chronic  iritis,  constitutional  treatment  is  usually  all 
that  is  required  for  relief. 

If,  however,  in  spite  of  all  treatment,  the  aqueous  humor 
becomes  very  cloudy,  the  pain  increases,  the  tension  becomes 
greater,  there  is  a  decrease  of  vision,  or  if  pus  forms  in  the 
anterior  chamber,  then  paracentesis  should  be  performed; 
but  if  the  disease  still  progresses,  with  an  increase  of  all  the 
above  symptoms  and  extension  of  the  inflammatory  processes 
to  the  deeper  structures  of  the  eye,  then  iridectomy  must  be 
resorted  to. 

Primary  cyclitis,  or  inflammation  of  the  ciliary  body,  is 


312  SYPIIIUS  np   THE  EYE 

\'cry  rare.  It  usuallx  follows  all'cctions  oi"  the  iris  or  tlio 
choroid. 

Tlu"  syniptDiiis  are  iiitt-iisc  pericorneal  injection  at  one  or 
more  jjoints,  opposite  any  one  of  which  there  is  retraction  of 
the  iris. 

Giimmata  are  also  sometimes  found  in  tiie  cihary  body. 

Choroiditis  occurs  in  three  forms:  (1)  phistic  choroiditis, 
or  choroiditis  cxuchitiva;  (2)  serous  choroiditis;  and  (3) 
parenchymatous  choroiditis. 

riastic  choroiditis,  or  choroiditis  exudativa,  is  characterized 
hy  tlie  formation  of  an  exudation  upon  the  surface  and  in 
the  substance  of  the  choroid. 

The  exudation  appears  lilve  yellowish-white  or  straw- 
colored  spots,  over  which  run  the  retinal  vessels.  These  spots 
may  be  absorbed  and  leave  no  trace  of  their  existence,  but 
usually  the  exudation  disappears,  leaving  atrophic  changes 
in  the  choroid,  which  becomes  greatly  thinned  and  allows 
the  sclera  to  be  seen,  thus  giving  a.  white,  glistening  appear- 
ance to  the  p!reviously  yellow  spots. 

Serous  choroiditis  is  characterized  by  the  exudation  of  a 
serous  material  from  the  choroidal  membrane. 

Parenchymatous  choriditis  consists  of  a  deep-seated  in- 
flammation with  hypertrophy  of  the  cellular  tissue,  forming 
little  gummy  tumors  which  project  into  the  vitreous  humor. 

Syphilitic  choroiditis  usually  develops  in  the  late  secondar}' 
or  the  early  tertiary  period. 

Retinitis,  or  inflammation  of  the  retina,  is  marked  by 
increased  vascularity  and  opacity  of  the  membrane,  due  to 
effusion  into  its  substance. 

It  usually  begins  by  redness  of  the  optic  nerve  entrance  or 
by  slight  edema,  which  obscures  the  underlying  structures. 
The  retinal  vessels  become  enlarged,  tortuous,  and  sometimes 


'ria<:.\TMKNT  ?A'.\ 

rupture,  Foniiinj^  si)()ts  of  (•ccliyiiiosis.  Tlic  (lc|>o.sit.s  ot* 
lym])li  ill  the  retina,  cause  Ii(j;li1-(()l(tn(|  palclie.s,  heiieatli 
which  i)ass  tlie  vessels  oi"  tli<'  dioroid  iiiid  the  retina. 

Retinitis  is  rather  an  nncoinmon  nl;lnil'(^-^t;l1i()ll  ;in<l  ffcncr- 
ally  occurs  quite  late  in  the  disease. 

Optic  neuritis,  unless  i'ollowiiif;  an  inflannnation  of  the 
retina  or  choroid,  is  \'ery  rare,  hut  does  occnr. 

The  ()j)hthahnoscopic  appearances  of  sjx'cific  and  non- 
specific neuritis  are  the  same. 

Syphilitic  paralysis  of  the  nerves  of  the  eye  is  a  not  un- 
common manifestation  of  the  disease  and  attacks  most 
frequently  the  third  pair,  or  motor  oculi;  next  the  sixth 
pair,  or  abducens;  and  finally,  the  fourth  pair,  or  patheticus. 

Paralysis  of  the  third  i)air  causes  i)tosis,  external  strabis- 
mus, immobility  of  the  ball,  diplopia,  and  mydriasis. 

Paralysis  of  the  sixth  pair  gives  rise  to  internal  strabismus. 

Paralysis  of  the  fourth  pair  is  followed  by  a  loss  of  power 
of  rotation  of  the  eye-ball  on  the  affected  side. 

Sometimes  only  certain  branches  of  a  nerve  are  involved, 
or  different  nerves  of  both  eyes  may  be  affected  simulta- 
neouslv. 


CHArTER   XXXIII. 
SVrilTTJS  OF  TTIE   EAPx. 

The  external  ear  iiia\-  he  the  seat  of  macules,  papules,  aiul 
gummata,  altliough  their  oeeurrenee  in  this  situation  is  not 
at  all  common. 

The  external  auditory  canal  is  sometimes,  but  not  very 
commonly,  the  seat  of  mucous  patches  and  condylomata; 
they  are  either  isolated  or  merged  together  and  may  com- 
pletely occlude  the  canal,  causing  quite  severe  pain. 

Ulcers  are  sometimes  situated  on  the  walls  of  the  external 
meatus;  they  are  rounded  in  form,  and  very  painful,  and 
begin  as  circumscribed  inflammations  or  gunniiatous  tumors 
which  may  break  down  and  suppurate. 

The  middle  ear  is  that  portion  of  the  organ  which  is  most 
frequently  affected  in  syphilitic  subjects  on  account  of  its 
intimate  connection  with  the  throat,  from  which  any  syphil- 
itic affection  may  extend,  and  in  which  place  syphilitic 
lesions  are  so  common. 

Mucous  patches  may  be  situated  in  the  Eustachian  tube 
or  upon  the  walls  of  the  middle  ear. 

The  sequelae  of  these  affections  may  be  thickening  or  de- 
struction of  the  drum,  loosening  of  the  ossicles  from  their 
attachments,  or  caries  of  the  temporal  bone  or  ossicles. 

The  mastoid  cells  may  also  be  involved  as  in  ordinary 
suppurative  otitis  media. 

Stricture  or  complete  occlusion  of  the  Eustachian  tube 
may  follow  an  acute,  severe  invasion  of  syphilis. 


SYPHILIS  OF   Tlll<:  J'JAli  315 

llypcrtropli}'  ol'  tl)c  liiiiiif^  iiiciiihraiie,  incinhranous  IjuikIs, 
polypi,  or  liyixirplasiu  of  the  osseous  tissues,  cause  imi)Mir- 
ment  of  hearing,  according  to  tlieir  degree  of  development. 

Li  cases  of  severe  inflammatic^n  of  tlu;  tympanum  there 
may  be  congestion,  or  even  extravasation  of  blood  into  tlu; 
Jnternal  car. 

Disease  of  the  hibyrinth  usually  appears  at  the  end  of  the 
secondary  stage  and  may  either  follow  disease  of  the  middle 
ear  or  occur  primarily. 

Cases  of  sudden  deafness,  due  to  syphilis,  may  occur 
during  both  the  secondary  and  tertiary  stages.  As  a  rule, 
both  ears  are  afl'ected  simultaneously. 

There  is  a  feeling  of  fulness  in  the  ear,  but  no  pain;  the 
patient  has  vertigo  and  sometimes  a  staggering  gait. 

The  attack  is  preceded  by  hyperemia  of  the  drums,  which 
afterward  become  opaque,  lustreless,  and  only  slightly,  if  at 
all,  injected;  there  is  no  sign  of  fluid  in  the  middle  ear.  The 
Eustachian  tube  remains  open  and  the  fauces  may  or  may 
not  be  affected. 


CHAPTKll  XXXIV. 
CONSTITUTIONAL  TKKATMHNT  OF  SYIMIILIS. 

The  constitutional  trcatniciit  of  syphilis  consists  in  the 
combined  use  of  mercury  and  saharsan  or  neosaharsan, 
with  the  addition  of  iodide  of  potash  in  certani  manifestations 
of  the  disease. 

During  the  entire  course  of  treatment  the  patient's  general 
condition  must  be  most  carefully'  watched  and  regulated 
by  the  employment  of  proper  hxgienic  measures  and 
other  medication,  as  indicated. 

Syphilitic  ])atients  should  lead  moderate,  temperate  and 
regular  lives,  with  nourishing  and  readily  digestible  diet. 

A  little  ale  or  beer  can  be  taken  at  lunch,  and  a  glass 
or  so  of  sherry,  claret,  burgundy,  or  white  wine  with  dinner; 
champagne  is  harmful,  as  are  also  brandy  and  spirits,  and 
these  should  therefore  not  be  allowed,  especially  on  an 
empty  stomach.  Drinking  between  meals  should  be  for- 
bidden. 

Smoking  may  l)c  permitted  in  great  moderation,  provided 
there  is  no  irritation  of  the  nasopharyngeal  mucous  mem- 
branes, and  that  none  results  frojn  the  use  of  the  tobacco. 

It  is  important  that  there  should  l)e  at  least  one  free 
evacuation  of  the  bowels  ever>-  day.  Moderate  exercise  in 
the  fresh  air  and  sunshine  must  be  insisted  n])on,  as  well  as 
daily  bathing  in  either  warm  or  cool  water,  whichever  is 
preferred;  as  by  these  means  the  secretory  apj^aratus  of  the 


CONSTITUTIONAL    I'HMAT M KNT  OF  SVl'flflJS     :',\7 

skin  is  koi)t  fiiiKiioiiiiliii^'  noriiuilly,  wliidi  is  very  essential 
in  these  eases. 

Jinssian  and  Turkish  })a,tlis  arc.  heiicficiai  in  sonic  eases,  as 
are  also  |)iaJn  hot,  salt,  or  sea  baths,  prov  idcd  they  are  taken 
in  moderation,  and  not  followed  by  the  cold  \)\u])^(;,  or 
shower,  the  shoek  of  whieh  is  very  harmful  and  even  danger- 
ous during  the  first  month  or  so  of  the  disease;  the  bath 
may  be  followed  by  massage.  Surf  bathing  slionid  never 
be  allowed  during  the  early  months. 

In  the  primary  stage  of  the  disease — that  is,  before  tiie 
appearance  of  tlie  roseola  or  macular  rash,  the  patient's 
general  health  must  be  thoroughly  investigated,  and  he  or 
she  put  in  as  good  physical  and  mental  condition  as  possible. 
The  teeth  and  gums,  as  well  as  the  mucous  membrane  of 
the  nose,  mouth,  and  throat,  and  also  that  of  the  entire 
gastro-intestinal  tract,  should  be  carefully  and  systematically 
examined,  and  put  in  thorough  order,  as  congested  mucous 
membranes,  rough,  dirty,  and  decayed  teeth,  and  spongy 
gums  cause  more  or  less  local  irritation,  whieh  is  the  prime 
factor  in  the  production  and  persistence  of  mucous  patches, 
and  is  in  many  cases  the  underlying  cause  of  salivation, 
when   mercury   is   administered. 

The  condition  of  the  kidneys  should  always  be  investigated 
at  this  time,  in  order  to  enable  us  to  differentiate  between 
an  ordinary,  preexisting  nephritis  and  that  jjossibly  due  to 
the  administration  of  mercury  or  arsenic.  Should  nephritis 
be  present,  these  remedies  must  be  administered  with  extreme 
care. 

Should  anemia  develop,  as  it  may  in  the  primary  and  the 
early  part  of  the  secondary  stages,  hematogenous  drugs 
must  be  administered,  such  as  iron  and  strychnin,  and,  if 
indicated,  arsenic. 


318     CONSTITUTIONAL   TREATMENT  OF  SYPHILIS 

Before  the  use  of  salvarsau  or  neosalvarsan  it  is  always 
imperative  also  that  the  eyes  be  carefully  examined,  to 
see  that  the  fundus  and  optic  disks  are  normal,  as  these 
structures  are  very  susceptible  to  arsenic-containing  drugs. 

ADMINISTRATION  OF  MERCURY. 

In  using  mercury  it  must  not  be  forgotten  that  in  certain 
instances  it  is  apt  to  cause  such  disagreeable  complications 
as  salivation,  stomatitis,  and  gastro-intestinal  disorders, 
but  fortunately  such  complications  at  the  present  time 
are  very  rare  indeed,  as  the  doses  employed  are  exact,  the 
preparations  more  carefully  selected,  and  the  gums,  teeth, 
and  mucous  membrane  put  in  good  order  when  the  disease 
is  first  diagnosed. 

^Mercury  may  be  administered  by  the  mouth,  by  in- 
unction, by  intramuscular  injection,  or  by  fumigation. 

Internal  administration:  If  the  drug  is  to  be  administered 
in  this  manner,  the  best  preparations  are  the  biniodide, 
protoiodide,  or  the  tannate  of  mercury,  given  in  i)ill  form, 
and  often  combined  with  iron  and  arsenic. 

The  dose  of  the  biniodide  or  protoiodide  is  from  a  (juarter- 
to  a  half-grain,  three  times  a  day;  while  that  of  the  tannate 
should  be  from  a  half-grain  to  a  grain. 

If  so  desired,  the  salicylate  or  thymolacetate  of  mercury 
may  also  be  used  in  pill  form,  in  from  half-  to  even  three- 
quarter-grain  doses;  practically,  however,  these  preparations 
have  no  advantages,  nor  are  they  even  as  efficient  as  those 
previously  mentioned. 

It  must  be  remembered,  moreover,  that  the  internal 
administration  of  mercury  is  much  more  liable  to  cause 
salivation  and  gastro-enteritis  than  the  inunctions  or  injec- 


ADMINIHTIIATION   Oh'   MKIldJUY  .''.10 

tioiis,  to  wliicli  it  is  Jar  inferior  in  every  resj)(;ct  us  rogjinJs 
the  ultinijttc  cure  of  the  })Jiti(!nt,  and  tliat  it  is  now  [)nif;ti(;ally 
a  thing  ot"  tlic  [)ast,  never  to  he  used  nnl(!ss  it  is,  for  some 
reason,  absolutely  iini)ossihlc  for  th(;  [)atient  to  take  any 
other  form  of  treatment. 

Inunction:  This  is  the  most  efficacious  and  rational  mode 
of  administering  mercury,  as  by  the  inunction  method  we 
obtain  not  only  the  constitvitional,  but  also  the  local,  action 
or  effect  of  the  drug,  and  at  the  same  time  sj)are  the  stomach. 
The  best  preparation  is  a  50  per  cent,  mercurial  ointment 
made  with  fresh  lard. 

The  part  to  be  rubbed  should  be  thoroughly  cleansed 
with  alcohol.  A  fresh  portion  of  integument  is  selected 
each  time,  and  rendered  clean  as  above  described,  as  in 
this  manner  irritation  of  the  integument  (dermatitis)  is  in  a 
great  measure,  if  not  wholly,  prevented. 

For  each  inunction  or  rubbing  from  twenty-five  to  sLxty 
grains  or  more  of  the  ointment  are  used,  which  is  carefully 
weighed  and  put  up  in  oiled  papers  or  gelatin  capsules,  thus 
making  the  method  an  exact  and  accurate  one  as  to  the 
amount  of  drug  used  at  each  rubbing.  The  inunctions  are 
best  given  by  a  professional  rubber,  although  patients  can 
rub  themselves,  if  necessary.  The  average  healthy  adult 
will  take  about  sixty  grains  of  the  50  per  cent,  ointment  at 
a  rubbing,  although  there  are  some  who  can  go  as  high  as 
seventy-five  and  even  eighty  grains. 

Each  rubbing  should  occupy  from  twenty  to  thirty 
minutes  in  order  that  the  ointment  may  be  well  rubbed  in, 
which  leaves  the  skin  of  a  grayish  color,,  and  not  markedly 
greasy  to  the  touch. 

If  the  inunctions  are  given  in  this  thorough  manner,  the 
treatment  is  not  as  irksome  as  it  is  described  by  some  writers ; 


320    CONSTITUTIONAL   TREATMENT  OF  SYPHILIS 

in  my  own  j)r;u'tu'e  1  c-xpcrifiKT  little  or  no  (liHicultx'  from 
patients  on  this  score  when  this  method  is  employed. 

To  protect  tiie  clothins;,  tliese  ])atients  can  wear  tiic  thin- 
nest kind  of  underclothes  over  the  i)art  last  rubbed. 

A  course  of  inunctions  consists  of  cIcncii  rul)l)in<i;s,  gi\en 
on  the  following  regions,  into  which  the  body  is  divided, 
so  that  at  the  end  of  each  course  the  entire  body  has  been 
treated,  with  the  exception  of  the  scalp  and  face,  both  of 
whicli  can  be  rubbed  on  alternate  nights  with  ammoniated 
mercurial    ointment    if   so   desired. 

Region  1.  The  entire  neck,  well  up  to  face  and  hair-line, 
and  down  to  clavicles. 

Region  2.  The  right  shoulder,  arm,  forearm,  and  hand 
(dorsum  and  palm). 

Region  3.  The  left  shoulder,  arm,  forearm,  and  hand 
(dorsum  and  ])alm). 

Region  4.  Right  half  of  chest  and  abdomen  (from 
chnicle  to  groin,  and  from  median  line  to  axillary  line). 

Region  5.  Left  half  of  chest  and  abdomen  (from  cla\icle 
to  groin,  and  from  median  line  to  axillary  line). 

Region  (>.  Right  half  of  back  (from  root  of  neck  to  but- 
tock, and  from  median  line  to  axillary  line). 

Region  7.  Left  half  of  back  (from  root  of  neck  to  l)uttock, 
and  from  median  line  to  axillary  line). 

Region  S.     liight  thigh  and  groin. 

Region  9.     Left  thigh  and  groin. 

Region  10.  Light  leg  and  foot  (dorsum  and  ])lantar 
surface). 

Region   1 1 .     Lcftlcgand  foot  (dorsum  and i)lantar surface). 

The  rubbings  should  be  given  every  other  night,  the  first 
one  not  being  washed  off  until  just  before  the  second  one  is 
administered,  and  so  on  throughout  the  entire  course. 


ADMJNISTUATIOS   OF   MKh'CHHY  321 

Wluwi  one  coiirsi!  of  imiiictioiis  i^  (iiii.^licd  (II  riil)l>iiigs), 
treatment  slionlfl  he  stopped  for  ;i  few  days  and  then 
resumed  in  the  Siinu!  rej^ional  manner  as  ahoxc  deserihed, 
the  integument  heini^;  tiioronj^iily  cleansed  hy  hot  soap-and- 
water  haths,  (hirin<;-  this  jx-riod  of  rest. 

For  rubhing  the  scalp  and  face,  we  employ  the  white 
precipitate  or  anunoniated  mercurial  ointment  on  account  of 
the  bluish-black  color  of  the  mercurial  ointment.  The.se 
parts  are  rubbed  two  or  three  times  a  week  during  the 
early  secondary  stage. 

Fumigation. — Fumigations  are  undoubtedly  of  great  value 
in  certain  of  the  chronic,  the  localized,  and  especially  the 
scaling  and  ulcerating,  eruptions  of  syphilis,  l)ut  must  not 
be  employed  as  a  routine  method  of  constitutional  treatment. 

The  mercurial  vapor  is  best  generated  from  calomel  and 
cinnabar  placed  on  a  Lee  fumigation  lamp. 

These  treatments  may  be  taken  at  home  or  at  a  regular 
bath  establishment,  whichever  the  patient  prefers;  the 
plnsician  always  prescribing  the  amount  of  drug  to  be  used 
at  each  bath,  and  never  leaving  it  to  the  discretion  of  the 
attendant. 

The  purest  calomel  and  cinnabar  (red  sulphide  of  mercury) 
must  be  employed,  and  the  body  or  the  part  to  be  acted  upon 
thoroughly  washed,  before  the  bath  is  given.  The  bath 
should  be  taken  at  night  just  before  retiring,  and  about 
twenty  grains  of  calomel  and  forty  grains  of  cinnabar  used; 
these  are  mixed  and  placed  on  the  lamp. 

The  patient,  undressed  and  covered  with  blankets,  sits 
on  a  cane-bottom  chair,  beneath  which  is  the  lamp;  in  a  few 
minutes  profuse  perspiration  comes  on,  the  drugs  being  com- 
pletely volatilized  in  about  twenty  minutes,  during  which 
time  steam  is  also  produced  from  the  water  bath  on  the 
21 


322    CONSTITUTIONAL   TREATMENT  OF  SYPHILIS 

lain]),  \\hicli  is  tlien  extinguished.  The  patient  remains 
on  the  chair  a  few  minutes  longer,  and  then  retires  in  the 
same  blanket,  ^vithout  being  rubbed. 

The  bath  may  be  given  every  night,  or  one  to  three  times 
weekly,  according  to  the  strength  of  the  patient  and  the 
amount  of  mercurial  effect  desired.  The  patient  should  be 
very  careful  not  to  catch  cold  after  the  treatment. 

While  this  method  is  of  undoubted  value  in  the  type  of 

lesions  mentioned,    it   is   now   practically    obsolete,   owing 

to  the  readiness  with  which  these  lesions  respond  to  the 

intravenous  injections  of  salvarsan  and  neosalvarsan,  com- 

*. 
bined  with  mercury.     It  is  described  here,  therefore,  rather 

for  its  historic  interest  than  as  a  practical  method. 

Intramuscular  injections:  The  treatment  of  syphilis  by 
intramuscular  injections  of  mercury  is  very  efficient;  but 
its  general  adoption  as  a  routine  method  of  constitutional 
treatment  cannot  be  recommended,  as  the  injections  are 
followed  by  more  or  less  pain,  soreness,  indurated  nodules, 
and  in  some  rare  cases  by  abscess  formation. 

The  ])reparations  of  mercury  used  may  be  either  soluble 
or  insoluble.  Of  the  former  the  best  is  the  bichloride  in 
sterile,  watery  solution,  ten  minims  containing  |  grain. 
The  dose  used  varies  from  T2^  to  j  or  even  ^  grain,  every 
three  to  five  days. 

Of  the  insoluble  preparations  the  salicylate  is  the  best. 
It  is  put  up  for  use  in  the  form  of  a  10  per  cent,  suspension 
in  sterile  albolene,  so  that  10  minims  equal  1  grain.  The 
dose  is  from  f  grain  to  1  grain  every  five  to  eight  days. 
The  mixture  must  be  thoroughly  shaken  just  before  use. 

The  injections  are  given  with  an  all-glass  (Fig.  129) 
hypodermic  syringe,  and  a  platinum  needle  about  an  inch 
and  a  quarter  long. 


ADMINISTh'ATlON  OF   MERCJJfiY  V>2'.'> 

The  site  of  the  iiij(icti()ii  is  sterilized  l>,y  jjiiiiitiiig  it  v\itli 
tincture  of  iodiii  iiiul  washing  with  95  per  cent,  alcohol. 
The  syringe  und  ncedh;  an;  l)()il(!d  and  th(;  surgeon's  hdiid- 
scruhlx'd   and   cleansed   as  for  any  operation. 

The  patient  slionid  he  on  his  side  or  ahdonien,  with  nniseles 
rehixed.  The  needle  is  inserted  at  right  angles  and  deeply 
into  the  muscle  and  the  solution  injected  slowly;  the  needle 
is  then  carefully  withdrawn,  and  the  puncture  wiped  o\\  with 
alcohol.  No  dressing  of  any  sort  is  required,  hut  the  injection 
site  should  be  massaged  with  sterile  gauze  for  a  few 
moments. 


FiG.  129. — All-glass  syringe  and  needle  for  intramuscular  injections. 

The  best  place  for  making  the  injection  is  into  the  upper 
and  outer  part  of  the  buttock. 

Iodide  of  Potash. — While  probably  not  possessed  of  any 
direct  effect  upon  the  Spirocheta  pallida  itself,  the  iodide  of 
potassium  is  a  very  useful  adjuvant  to  combine  with  mercury 
and  salvarsan  or  neosalvarsan,  as  it  hastens  elimination  and 
assists  greatly  in  the  breaking  down  of  syphilitic  deposits 
wherever  they  may  occur.  It  finds  its  greatest  field  of  use- 
fulness, therefore,  in  the  treatment  of  late  secondary  or  of 
tertiary  lesions,  and  in  most  cases  is  best  given  in  the  later 
stages  of  the  disease. 


o24    CONSTITUTIONAL  TREATMENT  OF  SYPHILIS 

The  dose  (»f  tlie  iodide  of  potash  in  the  beginning  should 
))e  t'roiii  about  fi\e  to  fifteen  grains,  three  times  a  day,  an 
hour  after  meals.  This  may  be  increased  gradually  to  one 
himdred  or  even  more  grains  daily. 

It  is  best  to  begin  with  ver\'  small  doses,  diluted  in  water, 
or  mixed  with  essence  of  ])ei)siii,  elixir  of  lactoix^ptine,  or 
milk  of  magnesia. 

In  some  instances  it  causes  coryza,  pain  in  the  frontal 
sinuses,  edema  of  the  conjunctiva,  swelling  of  the  lids, 
irritation  of  the  fauces,  gastro-intestinal  derangements,  or 
eruptions  on  the  skin,  most  commonly  papules,  acne  pustules, 
or  furuncles,  which,  as  a  rule,  are  situated  ui)on  the  face, 
the  neck,  and  the  back. 

In  large  and  long-continued  doses,  iodide  of  potassium 
may  sometimes  give  rise  to  a  condition  known  as  iodism, 
which  consists  of  a  feeling  of  oppression  in  the  head,  tinnitus 
aurium,  neuralgia,  spasmodic  muscular  action,  im])airment 
of  voluntary  motion,  and  sluggish  intellect. 

All  the  above  complications  rapidly  subside  on  the 
temporary  suspension  of  the  drug. 

Mixed  Treatment. — By  the  "mixed  treatment"  is  meant 
the  internal  administration  of  potassium  iodide  and  mercury 
in  combination. 

The  indications  for  the  use  of  the  ''mixed  treatment" 
are  the  same  as  for  the  internal  treatment  by  pills,  already 
mentioned.  In  other  words,  this  method  of  administration 
should  never  be  resorted  to  except  imder  conditions  which 
absolutely  preclude  the  use  of  inunctions  or  intramuscular 
injections  of  mercury  and  the  intravenous  administration 
of  the  new  arsenical  preparations. 

The  following  prescription  for  the  "mixed  treatment"  is  a 
good   working   formula,    but   may    have   to   be   somewhat 


ADMINIS'rh'A'riON  OF   MKIirUKY  32.') 

modified  iiccordiiif^  to  the  siiseeptiMlity  of  t  lie  pnt  iciit  ;iiid  1 1n- 
requirements  of  eueli  individual  ease. 

I^ — Hydrarg.  biiiiodid.,  Ki"-  j-ij   iij   iv 

PottiHs.  iodid.,  7)Vi-Z^^-?>i-?>^ 

Tinct.  gent,  co.,  ad      Jiv — M. 

Sig. — 3j  (,()  5ij  in  a  wineglass  of  waier,  one  f,o  t,wo  liour.s  after  each  meal, 

Zittman's  Decoction. There  is  always  a  small  percentage 
of  patients  who,  after  undergoing  antisypliilitie  treatment 
with  mercury  and  iodides  for  a  varying  length  of  time, 
begin  to  show  signs  of  anemia  and  defective  elimination, 
or  by  whom  the  regidar  antispecific  remedies  are  no  longer 
well  borne.  In  tliese  eases  the  use  of  the  following  modi- 
fication of  Zittman's  decoction  is  often  followed  by  marked 
improvement,  the  cathartic  and  tonic  action  of  the  mixture 
making  it  possible  for  the  patient  to  resume  regular  antiluetic 
treatment. 


I^ — Alum  pulv., 

3ss 

Fl.  ext.  sarsaparilL, 

5ij 

Glycerini, 

5J 

Syr.  sennse, 

Siss 

Sp.  anisi, 

3J 

Fid.  ext.  glj^cyrrhiz., 

Sj 

Aq.  fcBiiiculi, 

ad 

Sviij 

Sig. — §j  in  a  glass  of  water  after  meals. 

-M. 


During  the  time  that  this  treatment  is  being  employed 
patients  should  drink  freely  of  any  bland  water. 

Salivation. — During  a  course  of  mercurial  treatment  some 
subjects  are  liable  to  become  salivated,  especially  those  with 
bad  teeth  and  spongy  gums,  which  conditions  should  have 
been  corrected  in  the  primary  stage  of  the  disease. 

The  first  symptom  of  salivation  is  soreness  of  the  gums 
just  behind  the  superior  incisors,  and  in  the  lower  jaw  back 
of  the  last  molars;  the  other  symptoms  are  a  metallic  taste 
in  the  mouth,  fetid  breath,   increased  flow  of  the  saliva, 


326    CONSTITUTIONAL  TREATMENT  OF  SYPHILIS 

tenderness  of  the  teeth  when  elosed  n])on  eaeh  other, 
swelHng  of  the  tongue,  which  is  marked  by  tlie  teeth  on  its 
sides,  edema  of  the  nnieous  membrane  of  tlie  cheeks,  gums, 
and  lips,  with  difficulty  and  pain  in  articukition  and  de- 
glutition. In  some  cases  the  neighboring  lymphatic  glands 
may  become  enlarged  and  tender.  Sometimes  there  is  fever 
and  diarrhea,  accompanied  by  general  malaise.  In  some  verj' 
rare,  extreme  and  neglected  cases  there  is  ulceration  of  the 
soft  parts,  which  may  or  may  not  be  followed  by  necrosis  of 
the  maxillary  bones. 

Treatment. — The  mercurial  treatment  must  be  stoj^ped  im- 
mediately, the  bowels  freely  opened  with  saline  cathartics, 
and  the  patient  given  a  hot  soap  bath,  especially  if  taking 
inunctions  or  fumigations.  The  diet  must  be  liquid  and  nour- 
ishing. For  a  gargle  and  mouth-wash  we  can  use  solutions 
of  chlorate  of  potash  and  alum,  with  tincture  of  myrrh,  which 
must  be  employed  frequently.  The  line  of  juncture  of  the 
teeth  and  gums  may  be  painted  with  equal  parts  of  tincture 
of  iodin  and  tincture  of  myrrh. 

In  those  cases  in  which  the  teeth  and  gums  have  been 
neglected,  and  are  therefore  in  a  dirty  and  spongy  condition, 
thorough  cleansing,  at  frequent  intervals,  with  absorbent 
cotton  on  an  applicator  or  a  soft  brush,  is  very  useful. 

These  patients  must  be  kept  in  the  open  air  and  sunshine 
as  much  as  possible  and  given  tonics  as  indicated,  with 
plenty  of  easily  digestible,  nourishing  food. 

ADMINISTRATION  OF  SALVARSAN  AND  NEOSALVARSAN. 

The  successful  administration  of  salvarsan  and  neosal- 
varsan  requires  a  careful  technic,  but  one  which  is  neither 
complicated  nor  difficult  to  master. 


HALVAIiHAN   AND   N  EOS  A  LV  A  US  AN  327 

We  shall  lirst  dcscrilK!  tlic  udMiiiiistration  of  the  newer 
preparation,  iieosalvarsiiii,  as  the  stei)s  in  tlic  jjroeechire 
are  siini)l(T  tlian,  iiion^li  siniihir  to,  those  used  in  injecting 
salvarsan,  and  wiU  make  it  easier  to  in)(hTsf;ind  the  iirl- 
ministration  of  the  latter. 

Neosalvarsan  may  be  administered  either  intr;iiiiu^fiil;irl,\- 
or  intravenously. 

The  intramuscular  method  is  far  inferior  to  the  intra- 
venous, and  is  never  employed  by  the  author.  Witii  it  both 
the  absorption  and  the  elimination  of  the  drug  are  slow  and 
uncertain;  the  procedure  is  no  safer,  and  the  injections  are 
always  followed  by  more  or  less  pain,  b}'  edema,  and  by 
the  formation  of  large,  tender  nodules  in  the  tissues.  In 
many  cases  the  pain  and  swelling  are  so  severe  as  to  confine 
the  patient  to  bed. 

The  method  of  intravenous  administration  employed  by 
the  author  is  as  follows: 

The  necessary  apparatus  consists  of  two  graduated  glass 
jars  or  burettes,  having  a  capacity  of  50  c.c,  resting  in  a 
suitable  holder  and  coupled  together  by  glass  and  rubber 
tubing,  and  a  three-way  stopcock,  as  shown  in  Figs.  130 
and  131.  By  means  of  the  three-way  cock,  fluid  may  be 
drawn  from  either  jar  alternately,  as  desired. 

In  place  of  the  burettes  some  operators  use  Record 
syringes  of  about  20  c.c.  capacity,  but  the  writer  prefers 
the  jars,  as  the  fluid  then  enters  the  circulation  by  force  of 
gravity  only,  and  the  pressure  can  be  much  more  easily 
regulated. 

The  common  outlet  tube,  leading  away  from  the  tln-ee- 
way  cock,  ends  in  a  metal  nozzle  which  fits  accurately  into 
the  socket  of  the  needle  through  which  the  injection  is  made. 

There  are  various  models  of  needle  on  the  market;  the 


328    CONSTJTUTIOXM.    TRKATMEXT  OF  SYPIIJUS 

author's  i)ret'(.Tciicr  hv'iu^  for  tlie  Schreiber  needle,  shown 
in   Fiti'.    V-V2.     Xccdlcs  iiuist   he  sharp  and   free  from   rust, 


..^^..^^•C*! 


Fig.  130. — Salvarsaii  gravity  apparatus. 


SA  L  VA  nSA  N   AND   N  /'JOS  A  L  VA  L'SA  N 


320 


both  inside  and  out,  to  Jivoid  tin;  risk  ol"  l;i(,(Tiitioij  of  the 
vein  and  cloffjiiinfi;  ol'  \\\v.  flow  of  tlic  drn^.  J^'or  this  reason 
they  should  in)t  he  used  more  lh;ui  once  or  twice,  as  corrosion 
is  very  liable  to  occur  in  old  needles.  "^Fhe  most  useful 
calibers  are  18  and  20;  IS,  the  larger,  for  esfjeeially  larg(; 
and  prominent  veins,  and  20,  the  smaller,  for  the  average 


Fig.  131. — Autlior's  three-way  stopcock. 

man  and  for  women  and  children.  New  needles  should  be 
thoroughly  washed  out  with  alcohol,  before  sterilization, 
to  remove  all  traces  of  the  oil  with  which  they  are  often 
filled. 

The  burettes,  tubing  and  needle  must  be  sterilized  by 
boiling  and  then  allowed  to  cool  down  to  room  temperature 


Fig.  132. — Schreiber  needle. 


before  use.  The  two  jars  are  then  filled  with  sterile,  freshly 
distilled  water,  at  room  temperature,  enough  of  which  is 
run  out,  by  manipulation  of  the  stopcock,  to  completely 
fill  the  tubing  and  insure  the  exclusion  from  it  of  all  air 
bubbles.  The  water  in  one  jar  is  then  run  out,  down  to 
the  mark  zero,  while  the  other   jar   is   refilled   to    its    full 


3.30     COXSTITUriONAL   TREATMENT  OF  SYPHILIS 

capacity.  I'Accpt  for  the  addition  of  the  solution  of 
neosalvarsan  the  apparatus  is  now  ready  for  use. 

Tlie  preparation  of  the  patient  should  begin  the  day 
before.  He  should  undergo  a  careful  physical  examination, 
which  should  include  a  urinalysis,  a  Wassermann  reaction, 
if  he  has  not  lately  had  any  antisyphilitic  treatment,  and  an 
examination  of  the  eyes,  ears,  nervous  system  and  heart  and 
lungs.  Alcohol  should  be  avoided  for  at  least  twenty-four 
or  forty-eight  hours.  Dinner,  the  night  before,  and  breakfast, 
on  the  morning  of  administration,  nmst  be  very  light  and 
easily  digestible.  The  use  of  tobacco,  for  twelve  hours 
before,  is  also  to  be  forbidden.  The  bowels  should  be 
opened,  preferably  by  com})ound  cathartic  pills,  in  the 
evening,  and  a  saline,  in  the  morning.  The.  ])atient  should 
rest  for  at  least  a  half-hour  before  receiving  the  injection, 
and  should  drink  water  very  freely  both  before  and  after. 

The  apparatus  having  been  prepared,  as  described  above, 
the  patient  now  lies  down  on  an  operating  table,  with 
head  and  shoulders  somewhat  elevated,  and  allows  both 
arms  to  hang  down  over  the  sides  of  the  table,  so  as  to  dis- 
tend the  veins  with  blood.  That  arm  is  selected  for  the 
injection  in  which  the  superficial  veins  are  most  prominent. 
The  usual  site  is  into  the  median  basilic  or  median  cephalic 
vein,  but  any  vessel  which  is  sufficiently  large  may  be  se- 
lected. The  site  having  been  decided  on,  an  area  of  several- 
square  inches  about  the  point  of  puncture  is  sterilized, 
either  by  washing  with  soap  and  water,  followed  by  bi- 
chloride solution,  or  by  painting  with  tincture  of  iodin  and 
washing  with  alcohol.  The  arm  is  then  covered  with  a 
sterile  towel  and  left,  thus  protected,  in  a  dependent  position 
until  ready  for  injection. 

The  ampoule  containing  the  drug,  sterilized  by  soaking 


><?ALVAIiSAN  AND  NI'JOSALVARSAN  'VM 

ill  ;ilc(jlic)l,  is  now  wiped  (lr.\'  mikI  opeiicfl,  hy  scrutcliiii;;  uiid 
breaking  od'  the  neck  with  a  sterile  file,  and  tlie  entire 
contents,  a  yellowish  powder,  dissolved  in  15  to  20  c.c.  of 
cold,  frefihly  didilled,  sterile  water.  When  the  flrug  is 
('oni])letoly  dissolved  the  solution  is  poured  into  the  emi)ty 
burette,  and  we  are  ready  to  proceed  with  the  injection. 

The  })atient  having  been  instructed  to  lie  very  still  and 
to  hold  the  forearm  supinated,  with  the  fist  clenched,  in 
order  to  make  the  veins  of  the  forearm  as  prominent  as 
possible,  a  tourniquet  of  rubber  tubing  is  applied  two  or 
three  inches  above  the  elbow,  with  the  limb  still  hanging 
down.  The  arm  is  then  supported,  in  a  sloping  position,  by 
sand-bags  covered  with  sterile  towels.  As  soon  as  the  selected 
vein  is  well  distended  the  operator,  holding  the  needle  so 
that  his  thumb  rests  in  the  concavity  of  its  curve,  plunges 
its  point  through  the  skin  over  the  vein  and  then  into  the 
vessel  itself.  The  fact  that  the  vein  has  been  entered  is 
shown  by  a  flow  of  blood  through  the  needle. 

The  tourniquet  is  immediately  removed,  slowly  and  gently, 
to  avoid  jarring  the  limb,  and  the  assistant  starts  water 
flowing  from  the  water-jar,  at  the  same  time  handing  the  end 
of  the  tubmg  to  the  operator,  who  fits  it  into  the  socket 
of  the  needle,  takmg  care  that  both  blood  and  water  are 
flowing  freely  at  the  time  the  coupling  is  made,  to  avoid 
the   entrance   of   air   bubbles. 

If  the  fluid  flows  freely  into  the  vein,  without  causing  any 
pain  or  distention  in  the  perivascular  tissues,  we  know 
that  the  needle  point  is  not  only  in  the  vessel,  but  that  it 
has  not  lacerated  its  wall,  so  as  to  permit  of  leakage  through 
it.  Should  smarting  or  swelling  occur,  however,  the  needle 
must  be  withdrawn  and  inserted  elsewhere,  and  the  process 
repeated,  for  while  the  escape  of  water  into  the  tissues  is 


332    CONSTITUTIONAL   TREATMENT  OF  SYPHILIS 

cjuitc  liarniless,  that  of  the  (Iriit;-  is  followed  hy  more  or  less 
severe  local  reaction,  which,  in  the  case  of  sulvarsaii,  is  even 
liable  to  go  on  to  tissue  necrosis.  \Yhere  leakage  of  even 
distilled  water  occurs  the  arm  should  be  dressed,  after  the 
injection  is  finished,  with  a  wet  dressing  t)f  aluminum 
acetate  or  weak  bichloritle  solution. 

If  the  flow  of  water  is  free,  however,  the  drug  is  turned  on; 
and  wlien  the  required  amount  has  lieen  injected  a  few 
cubic  centimeters  of  water  are  again  run  through  to  wash 
into  the  vein  any  of  the  neosalvarsan  solution  remaining  in 
the  tubing.  The  needle  is  then  quickly  withdrawn  and  a 
pad  of  sterile  gauze  fastened  over  the  site  of  puncture  with 
a  little  adhesive  plaster.  This  can  ])e  renio\ed  in  twenty- 
four  hours. 

The  administration  of  salvarsan  is  somewhat  more 
complicated  than  that  of  neosalvarsan,  owing  to  the  fact 
that  solutions  of  it  in  distilled  water  are  acid,  instead  of 
neutral,  and  therefore  require  to  be  alkalinized  by  the  ad- 
dition of  sodium  hydroxide,  and  also  because  much  less 
concentrated  solutions  can  be  used.  The  burettes  therefore 
must  be  of  300  c.c.  capacity,  instead  of  50. 

The  duration  of  the  injection,  as  a  result,  is  from  ten 
to  twenty-five  minutes,  instead  of  one  or  two  minutes,  as  is 
the  case  with  neosalvarsan. 

The  alkaline  injection  solution  is  prepared  as  follows: 

Into  a  300  c.c.  sterile,  glass-stoppered  graduate  pour 
the  contents  of  an  ampoule  of  salvarsan  and  40  c.c.  of 
fresh  sterile  0.5  per  cent,  sodium  chloride  solution  prepared 
from  freshly  distilled  water.  Shake  vigorously  until  the  drug 
is  complefely  dissolved.  To  this  clear,  acid  solution  must 
be  added,  according  to  the  amount  of  salvarsan  present,  a 
certain  luunber  of  drops  of  a  15  per  cent,  solution  of  sodium 


SALVARSAN   AND  N  f'JOSALVA  fiSAN  333 

hydroxide,  iiijmK;  up  with  sterile  distilled  water.  Ahout 
I'oiir  dr()|)s  of  this  solution  ;ire  lisually  rccjiiired  lor  each 
0.1    ^111.   ol'  the  driiji;;  thus: 


Solution  of  sodium  hytlroxiil'; 
(I^ — Purified  sodium  hydroxido     l.T)  tcraitiH 
Salvarsan.  Distilled  water      ....     8..0  c.c; 

0 . 6  gram  1 .  308  grams  =  approx.  1 .  14  c.c.  =  approx.  2.3  to  24  drops. 

0.5      "  1.090       "  =         "        0.9.5  c.c.  =         "        19  to  20       " 

0.4      "  0.872       "  =        "       0.76  c.c.  =        "        1.5  to  Ifj       " 

0.3      "  0.654       "  =         "    .    0.57  c.c.  =         "        12 

0.2      "  0.436       "  =        "       0.38  c.c.  =        "         8 


The  requisite  iiunil)er  of  drops  having  been  added  to 
the  sohition  in  the  graduate,  this  is  shaken  up  again  to  re- 
dissolve  the  precipitate  which  results  from  the  addition 
of  the  alkali.  When  the  solution  is  once  more  perfectly 
clear  we  then  add  sufficient  0.5  per  cent,  sodium  chloride 
solution,  sterile  and  made  up  with  freshly  distilled  water, 
to  make  a  total  volume  of  50  c.c.  to  every  0.1  gm.  of  sal- 
varsan present  (e.  g.,  0.5  gm.  should  be  contained  in  a 
total  volume  of  250  c.c).  If  the  solution  is  clear,  it  is  now 
ready  for  administration;  should  it  become  slightly  cloudy, 
however,  after  standing  for  a  few  minutes,  we  must  add 
more  sodium  hydroxide  solution,  a  drop  at  a  time,  waiting 
two  or  three  minutes  after  each  drop,  to  give  the  cloud  time 
to  disappear. 

When  a  perfectly  clear  solution  has  been  obtained  the 
drug  is  administered  precisely  as  is  neosalvarsan,  except  that 
the  jars  of  the  apparatus  are  of  300  c.c.  capacity  and  that 
more  time  is  required,  owing  to  the  larger  volume  of  fluid. 

As  stated  at  the  beginning  of  Chapter  XXXIV,  the 
complete  treatment  of  syphilis  includes  the  combined  use 
of  salvarsan  or  neosalvarsan  with  mercury  and  iodide  of 
potash.    The  methods  of  administration  of  these  drugs  ha^-e 


334     CONSTITUTIONAL  TREATMENT  OF  SYPHILIS 

now  been  discussed,  and  it  only  remains  to  indicate  how 
they  may  best  be  combined  and  how  lony-  the  treatment 
should  continue. 

Before  the  treatment  is  begun  the  patient  should  be 
thoroughly  examined  as  to  general  condition,  weight,  blood- 
pressure,  condition  of  the  urine  and  habits  and  mode  of  life. 
This  done,  the  more  rapidly  he  can  be  put  on  acti\'e  anti- 
syphilitic  treatment,  both  constitutional  and  local,  when  the 
latter  is  indicated,  the  better. 

^Vhile  no  hard-and-fast  rules  can  be  laid  down  as  to 
dosages  or  duration  of  treatment,  in  a  general  way  it  may 
be  said  that  while,  with  the  use  of  salvarsan  and  neosalvarsan, 
the  prospects  for  complete  cure  are  far  greater  than  formerly, 
yet,  at  the  same  time,  the  duration  of  treatment  should, 
as  before,  be  not  less  than  two  years,  and  longer,  if  possible. 

During  the  first  year  the  patient  should  receive  six  to 
eight  intravenous  injections  of  salvarsan  or  ten  to  twelve 
of  neosalvarsan,  given  at  intervals  of  seven  to  ten  days, 
depending  on  the  condition  of  the  kidneys.  The  initial 
dosage  should  be  about  half  the  possible  maxinunn,  the 
latter  being  reached  at  the  second  or  third  injection,  if  no 
untoward  results  follow  the  first.  At  the  same  time  the 
patient  should  begin  taking  inunctions  of  mercurial  oint- 
ment, 50  per  cent.,  as  described  abo\'e,  at  such  a  rate  that, 
at  the  end  of  the  first  year,  ten  to  twelve  "courses"  have 
been    taken. 

Iodide  of  potash  should  be  given,  in  increasing  doses,  up 
to  the  limit  of  tolerance,  after  about  the  second  or  third 
month  of  treatment. 

In  the  second  year  the  course  to  be  followed  is  similar 
to  the  above,  but  less  drastic,  and  with  longer  intervals 
of  rest  from  medication. 


l^AI.VAH^AN  AND  N liOHALV AliHAN  335 

()(;c;isi()iiully,  in  those  cases  tliut  reuet  poorl,}  to  treutiiieiit, 
in  whom  digestion  and  elimination  are  faulty,  the  ad- 
ministration of  tlic  modified  Zittman  decoction,  descril^ed 
on  p.  325,  will  be  followed  by  great  improvement  in  the 
patient's  general  condition  and  an  increased  ability  to  take 
vigorous  antisyphilitic  treatment. 

The  Wassermann  Reaction. — It  is  not  worth  while  to  test 
the  complement-fixation  reaction  until  after  the  end  of 
the  second  year.  After  that  time,  the  patient  having  gone 
six  or  eight  weeks,  at  least,  without  any  treatment,  a  test 
can  be  made,  which,  if  negative,  should  be  repeated  at 
intervals  of  a  few  months.  If  a  succession  of  negative  re- 
actions is  obtained,  over  a  period  of  years,  we  can  then 
feel  reasonably  certain  of  the  patient's  having  been  cured, 
provided,  of  course,  that  he  has  also  been  completely  free 
from  symptoms  during  that  time. 

It  is  well  to  remember,  here,  that  some  cases  prove  more 
refractory  to  treatment  than  others,  and  that  the  two  years' 
course  outlined  above  represents  the  minimum  duration  and 
may,  in  many  cases,  require  to  be  greatly  extended. 


C  H  A  P  T  E  R  X  X  X  X. 
HEREDITARY  SYPHILIS. 

Hereditary  or  congenital  syphilis  is  that  form  of  the 
disease  in  which  it  is  transmitted  to  the  fetus  in  idem  from 
cither  one  or  both  parents. 

As  a  general  rule,  symptoms  apj^ear  about  the  third  week 
of  life,  but  they  are  sometimes  obser^'ed  at  l)irth,  or  e\'en 
as  late  as  puberty  or  early  adolescence. 

If  both  parents  are  syphilitic  the  fetus  is  often  stillborn, 
or  the  child  may  manifest  symptoms  at  birth. 

The  severity  of  the  disease  decreases  with  each  succeeding 
child,  and  is  in  proportion  to  its  intensity  in  either  one  or 
both  parents  at  the  time  of  its  conception.  It  is  usually 
only  transmitted  to  the  second  generation,  although,  of 
late  years,  a  number  of  instances  have  been  reported,  in 
which  the  disease  was  apparently  transmitted  to  the  third 
generation. 

There  is  no  initial  lesion  nor  are  there  any  regular  stages 
in  hereditary  syphilis;  the  lesions  are  usually  more  hyper- 
emic  and  active  than  in  the  acquired  form,  and  attack  every 
organ  and  tissue  in  the  body. 

In  hereditary  syphilis  there  is  no  general  adenopathy, 
as  in  the  acquired  form,  although  groups  of  glands  may  be 
enlarged,  according  as  they  are  in  relation  with  active 
lesions. 

Hereditary  syphilis  may  be  derived   from   either  one  or 


HEREDITARY  HY  I'll  I  US  Vi'M 

both  |)iir('iit,s.  ir  prncrcid  ion  occurs  while  llic  I'litlicr  i^  in 
the  first  [X'riod  of  in(;iil)ation  tlie  child  will  cscupe  infection, 
and  may  do  so  even  if  he  be;  in  the  seeond  period  of  ineiif)a- 
tioii,  but  is  usually  itifected  if  he  has  secondary  manifesta- 
tions, although  constitutional  treatment  in;iy  so  niodil'y 
th(>  disease  in  the  father  that  the  child  will  escape,  even 
during  the  first  year. 

The  father  transmits  his  disease  through  his  sperm  cells, 
which  come  in  direct  contact  with  the  ovule  f)f  the  female 
at  time  of  fecundation. 

The  mother  may  also  transmit  syphilis  to  the  fetus,  but 
her  disease  must  be  constitutional,  as  at  that  time  her  ovule 
is  syphilitic,  and  the  fetus  is  thus  infected  at  the  time  of 
fecundation.  The  disease  of  the  mother  may  be  so  modi- 
fied by  constitutional  treatment  that  the  child  will  escape 
infection. 

In  those  cases  in  which  the  father  and  fetus  are  both 
syphilitic  and  the  mother  apparently  healthy,  though  re- 
fractory to  syphilitic  infection,  it  can  now  be  shown  by  the 
complement-fixation  test  that  the  disease  is  really  present 
in  the  mother  also,  but  in  a  condition  of  latency. 

The  syphilis  of  the  mother,  acquired  during  pregnancy, 
may  be  conveyed  to  the  fetus  through  the  uteroplacental 
circulation,  and  the  mother  may  also  be  infected  by  a 
sj^philitic  fetus  through  the  uteroplacental  circulation. 

The  course  of  the  disease  is  chronic  and  very  irregular 
in  character  in  those  cases  where  treatment  is  inadequate. 
Cutaneous,  mucous,  and  visceral  lesions  may  be  present 
at  the  same  time. 

The  duration  of  hereditary  syphilis  depends  upon  the 
intensity  of  the  disease  and  the  treatment  employed.  The 
lesions  respond  as  readily  to  modern  treatment  as  do  those 
22 


338  HEREDITARY  SYPHILIS 

of  the  acquired  form  of  the  disease,  but  it  is  i^articuhirly 
difficult,  in  hereditary  syi)liiHs,  to  render  tlie  Wasserniann 
reaction  negative  and  keep  it  so. 

The  mortaUty  of  syphihtic  cliildren,  althoug;h  quite  liigh, 
is  not  as  great  as  in  former  years,  owing  to  tlie  improved 
methods  of  treating  the  parents,  as  a  result  of  which  the 
fetus  may  even  escape  infection,  or,  if  infected,  the  disease 
itself  he  rendered  less  severe. 

Abortion. — Syphilitic  women  are  very  liable  to  abort,  and 
generally  do  so  between  the  fifth  and  seventh  months  unless 
adequately  treated.  Abortion  caused  by  the  death  of  the 
fetus  takes  place  at  about  the  sixth  month.  The  fetus  is 
usually  macerated,  of  a  purple  color,  with  various  visceral 
lesions  and  bulla?  upon  the  soles  and  palms. 

Syphilitic  stillborn  children,  or  those  dying  soon  after 
birth,  frequently  have  no  cutaneous  lesions,  but  have  a 
peculiar  senile  appearance. 

The  majority  of  syphilitic  children  born  alive  look  per- 
fectly healthy^  but  at  about  the  end  of  the  third  week  the 
disease  manifests  itself;  some,  however,  exhibit  cutaneous 
lesions  at  birth. 

Prognosis. — ^The  prognosis  of  hereditary^  syphilis  is  usually 
unfavorable,  but  depends  greatly  upon  the  condition  of 
the  parent  or  parents  at  the  time  of  conception,  the  inten- 
sity of  the  disease  in  the  child,  and  whether  the  infant  and 
the  infected  parent  or  parents  have  received  proper  anti- 
syphilitic  treatment  for  a  sufficient  length  of  time. 

The  prognosis  should  therefore  always  be  made  in  a 
guarded  manner,  and  after  a  careful  weighing  of  the  above 
stated  considerations.  It  is,  however,  not  now  as  unfavor- 
able as  in  former  years,  owing  to  our  improved  methods 
of  treatment,  not  only  of  the  parents,  but  also  of  the 
child  itself. 


CHAPTER  XXXVI. 
LESIONS  OF  IIEliEDlTAllY  SYPHILIS. 

THE    SYPHILIDES. 

The  commonest  eruptions  of  hereditary  syphilis  are  the 
erythematous,  the  papular,  the  vesicular,  the  pustular,  tlje 
bullous,  and  the  tubercular  syphilides. 

The  erythematous  syphilide,  or  roseola,  is  the  first  erup- 
tion, and  appears  about  the  third  week  of  life;  it  may  be 
preceded  or  accompanied  by  coryza.  Beginning  upon  the 
lower  portion  of  the  abdomen  as  pmk  spots,  the  eruption 
finally  invades  the  trunk,  the  face,  and  the  extremities; 
the  spots  gradually  assume  a  dull  red,  coppery  color,  which 
does  not  disappear  on  pressure,  owmg  to  the  pigmentation 
of  the  skin.  As  a  rule,  there  is  no  elevation  or  desquama- 
tion of  the  spots,  except  in  severe  cases,  or  when  they  are 
situated  upon  the  palms,  the  soles,  or  the  nates.  In  some 
instances  the  spots  coalesce,  forming  fissures  which  may  or 
may  not  be  painful.  The  eruption  may  be  so  faint  in  some 
cases  as  to  escape  observation. 

The  Papular  Syphilide. — This  syphilide  is  sometimes  the 
first  to  appear,  or  may  be  intermingled  with  the  erythema- 
tous eruption.  The  lesion  consists  of  large  and  small,  flat 
papules,  scattered  over  the  body.  Grouping  is  infrequent 
except  at  a  late  period,  and  then  occurs  about  the  joints  and 
on  the  extremities.  The  papules  are  coppery  red  in  color, 
and  may  exfoliate,  especially  when  situated  upon  the  palms 
or  soles, 


340  LESIONS  OF  HEREDITARY  SYPHILIS 

Condylomata  lata  are  really  iiothiiii;'  more  than  modifiefl 
j^apuies,  which,  being  situated  hetween  opposed  surfaces  of 
skin,  at  mucocutaneinis  junctions,  or  where\er  there  is  mois- 
ture, become  hypcrtro})hic.  They  vary  in  size  and  shape, 
are  of  a  grayish-pink  or  brown  color;  the  surface  is  flat, 
sometimes  fissured  and  ulcerated,  with  an  offensive  and 
highly  infectious  secretion;  they  appear  early,  run  a  chronic 
course,  and  are  most  frequently  encountered  about  the  anus. 
^Yith  ])r()])er  treatment  they  (lisai)])ear,  leaving  copper-col- 
ored pigmentations,  which  finally  fade. 

The  Vesicular  Syphilide. — This  syphilide  is  rare  and  occurs 
as  an  early  manifestation.  It  appears  in  groups,  situated 
upon  the  chin,  about  the  mouth,  upon  the  forearms,  the 
nates,  the  hypogastrium,  and  the  thighs,  and  is  usually 
associated  with  a  bullous  or  pustular  eruption. 

The  ^'esicles  may  be  large  or  small,  are  situated  upon  an 
infiltrated  base  of  a  brownish-red  color,  and  contain  serum 
or  seropurulent  fluid. 

The  Pustular  Syphilide. — This  syphilide  generally  appears 
before  the  eighth  week;  it  may  involve  the  entire  body,  but 
is  usually  most  marked  upon  the  thighs,  the  buttocks,  and 
the  face. 

The  pustules  vary  in  size  and  are  situated  on  a  thickened, 
deep  red  base;  they  sometimes  rupture,  leaving  an  ulcerated 
surface,  which  may  or  may  not  become  incrusted. 

Those  about  the  mouth  have  a  tendenc}'^  to  coalesce. 
Groups  of  pustules  are  liable  to  form  in  the  palms  or  soles, 
or  develop  around  the  nails,  and  finally  destroy  them.  If 
the  scalp  is  invaded  there  is  usually  some  resulting  alopecia. 

The  Furuncular  Syphilide. — Furuncles  are  liable  to  appear 
as  early  as  the  sixth  month,  or  as  late  as  the  third  year,  and 
may  occur  either  alone  or  associated  with  other  lesions. 


THE  MUCOUS  M EM B HANKS  'AW 

'J'lioy  roriii  slowly  iiiid  without  jiny  si^ns  of  iiifliuinii;i,f ion, 
tlui  biisc  being  ol"  a.  (•oj)p('ry-r('(l  color.  Snpcrficial  nlccratioii 
occurs  on  the  a,i)cx,  Icavimg  a  deej)  nicer,  with  excrlcd  mar- 
gins, Jind  a  scanty,  oil'ensive  secretion. 

The  bullous  syphilide,  or  ])ern])higus,  always  indicates  a 
severe  and  often  fatal  form  of  hereditary  syphilis;  it  may 
occur  at  birtli,  or  from  a  month  to  six  weeks  afterward. 

'^riie  j)ahns  and  soles  are  most  frequently  invaded,  alt  hough 
any  portion  of  the  body  may  be  attacked. 

The  bullse  are  conical,  rounded,  or  flattened,  and  ctjiitain 
seropurulent  fluid,  which  soon  becomes  purulent;  the  sur- 
rounding skin  is  thickened  and  of  a  copper  color.  After 
rupturing,  their  course,  when  untreated,  is  chronic  like  that 
of  the  pustules. 

The  Tubercular  Syphilide. — This  eruption  may  occur  as 
early  as  the  sixth  month,  or  even  several  years  after 
birth. 

It  begins  as  deep-seated  nodules  or  papules;  these  impli- 
cate the  integument,  forming  sharply  circumscribed  tiunors, 
which  either  disappear  or  break  down  into  ulcers.  The  sur- 
face of  the  tubercles  may  be  scaly,  looking  somewhat  like 
psoriasis.  They  are  usually  found  where  the  connective 
tissue  is  loose  and  abundant. 

Gummata  and  Gummatous  Ulcers. — These  manifestations 
of  the  disease  usually  occur  between  the  third  and  the 
twentieth  years.  Their  course  is  similar  to  those  in  the 
acquired  form. 

THE   MUCOUS   MEMBRANES. 

One  of  the  first  symptoms  of  hereditary  syphilis  is  'snuf- 
fing, accompanied  by  a  profuse  or  scanty  serous  discharge 


342  LESIONS  OF  HEREDITARY  SYPHILIS 

from  the  nostrils,  which  is  duo  to  u  structural  change  in  the 
nasal  mucous  membrane. 

The  secretion  becomes  purulent,  bloody,  offensive,  and 
highly  infectious,  causing  edema  and  excoriation  of  the  nose 
and  the  ui)1kt  lip,  upon  which  crusts  may  form. 

The  lesion  begins  as  a  simple  erythema  of  the  nnicous 
membrane,  ulceration  ensues,  and  the  disease  may  then 
extend  to  the  bony  and  cartilaginous  framework  of  the 
nose,  causing  its  destruction,  with  more  or  less  resulting 
deformity  (saddle-nose) . 

Mucous  Patches. — These  lesions  are  at  first  whitish  in 
color,  elevated,  and  surrounded  by  an  erythematous  border; 
the  epithelium  is  soon  remo\'ed,  leaving  a  slightly  depressed, 
red,  and  ulcerated  surface. 

Mucous  patches  are  most  commonly  situated  at  the  angle 
of  the  mouth,  upon  the  mucous  membrane  of  the  cheeks, 
the  fauces,  the  tonsils,  the  sides  and  dorsum  of  the  tongue, 
and  on  the  gums,  near  the  teeth. 

The  secretion  from  the  patches  is  free,  serous  in  character, 

and  highly  contagious,  so  that  great  care  must  be  exercised 

to  guard  against  the  infection  of  others,  especially  healthy 

'  wet-nurses,  who  would  naturally  be  infected  on  the  nipple 

or  breast  by  nursing  such  children. 

It  has  been  observed  that  a  child  suffering  from  hereditary 
syphilis,  whose  mother  is  api)arently  healthy,  may  nurse  at 
the  mother's  breast  without  infecting  her.  (Colles's  law.) 
This  has  been  taken  as  proving  that  the  mother  has  become 
immune  to  the  disease,  though  never  infected.  Present- 
day  experience  with  the  Wassermann  reaction,  however, 
suggests  more  and  more  strongly  that  such  mothers  are,  in 
reality,  syphilitic,  but  that,  in  them,  the  disease  is  in  a  con- 
dition of  latency. 


77//';    UMSI'lllATORY  OUdANH  313 

Gummatous  Infiltrations.  'V\\v,  k^sioiis  {fcncnilly  ofciir  Ix,- 
twccii  the  lliini  ;ui(l  \\w.  twclltli  ycurs. 

They  consist  of  w.  cclliihir  iiifiltriif ion  of  the  nnicoiis  mciii- 
l)riui(>,  wliiclv  at  first  bccoincs  reddened  and  elevated,  and 
finally  devel()])s  into  well-marked  tumors,  wliieh  nsnaliy 
break  down  into  undermined  ulcers,  with  a  };reeni>li,  thick 
secretion. 

Their  favorite  sites  are  the  hard  palate  and  the  y)osterior 
l)haryngeal  wall. 

THE   RESPIRATORY    ORGANS. 

Durmg  the  early  years  of  syphilis  the  larynx  may  l)e  the 
seat  of  simple  hyperemia,  of  mucous  patches,  or  of  ulcera- 
tion, which  involves  either  the  mucous  membrane  alone  or 
the  cartilage  beneath  it. 

Gummatous  infiltrations  of  the  larynx  belong  to  the  later 
stages  of  the  disease. 

Upon  the  surface  of  the  lung,  and  scattered  through  its 
substance  on  the  smaller  vessels  and  bronchi,  numerous 
nodules,  differing  in  size,  and  varymg  in  color  from  a  grayish 
pink  to  a  light  yellow  may  occur;  the  pleura  near  these 
nodules  becomes  opaque  and  thickened. 

An  entire  lung,  or  only  portions  of  a  lobe,  may  be  involved. 

The  morbid  process  begins  by  congestion,  followed  by 
cell-proliferation  around  the  bronchioles  and  in  the  walls 
of  the  capillaries,  causing  partial  or  complete  occlusion  of 
their  lumen,  and  destruction  of  the  function  of  the  lung. 
The  nodules  consist  of  connective-tissue  cells,  of  fibrinous 
and  of  gummatous  tissue,  and  may  undergo  fatty  or 
caseous  degeneration.  True  gummatous  nodules  do  some- 
times occur. 


344  LESIONS  OF  HEREDirARY  SYPHILIS 

These  lesions  are  most  frequently  encountered  within  the 
first  eighteen  months  of  iifi-. 


THE    ALIMENTARY    CANAL. 

It  is  thought  by  some  observers  that  the  chronic  diarrhea 
met  with  in  syphilitic  children  is  due  to  an  erythema  of  the 
gastro-intestinal  mucous  membrane,  similar  to  the  erythema 
occurring  in  the  mouth  and  pharynx. 

The  liver  may  be  the  seat  of  a  connective-tissue  infiltra- 
tion, which  renders  it  hard,  lobular,  and  hypertrophied ; 
these  changes  are  either  circumscribed  or  general. 

This  new  indurated  tissue  causes  the  capillaries  to  become 
obliterated,  and  the  caliber  of  the  larger  vessels  to  be 
diminished,  and  also  compression  of  the  cells  of  the  acini, 
with  cessation  of  the  flow  of  bile. 

Gummatous  hepatitis  occurs  either  as  numerous  small 
tiunors,  scattered  through  the  substance  of  the  liver,  or  as 
one  or  more  isolated  larger  masses. 

During  the  early  stages  of  the  disease  the  spleen  may 
become  more  or  less  hypertrophied,  but  this  enlargement 
yields  readily  to  constitutional  treatment. 

The  enlargement  is  very  great,  rapid  in  its  course,  and 
most  marked  in  cachectic  children,  and  those  in  whom  the 
disease  is  of  a  severe  type. 

The  pancreas  may  become  enlarged  and  firm  in  consistence. 
The  interstitial  connective  tissue  is  increased,  especially 
between  the  larger  lobules,  causing  compression  of  them, 
with  atrophy,  and  fatty  degeneration  of  their  epitheliinn. 


77//';   NAILS  345 

THE    GENITO  URINARY    ORGANS. 

In  the  kidneys  the  lesion  consists  of  a  cliH'use  or  eireurn- 
scribed  infiltration  of  small  romul  or  fusiform-shaped  cells 
into  the  connective-tissue  framework,  followed  hy  compres- 
sion or  destruction  oC  the  tuhnles  ;ind  colloid  dc<^rciicratif)n 
of  their  ei)ithelium;  the  organs  are  at  first  enlarged,  hut 
gradually  become  greatly  reduced  in  size. 

The  suprarenal  capsules  sometimes  become  enlarged,  owing 
to  the  proliferation  of  young  connective-tissue  cells. 

When  the  testicles  are  afl'ected  the  disease  consists  of  a 
chronic,  painless  enlargement  of  one  or  both  organs,  gener- 
ally accompanied  by  hydrocele  and  hyperemia  of  the  scro- 
tum.    The  epididymis  and  cord  are  sometimes  invoKed. 

The  lesion  consists  of  a  connective-tissue  proliferation, 
either  interstitial  or  diffuse. 

If  commenced  at  an  early  date,  constitutional  treatment 
causes  speedy  resolution;  but  if  neglected,  atrophy  or  degener- 
ation with  abscess-formation,  followed  by  fungous  protrusion 
of  the  testicle,  may  occur. 

In  all  probability  the  ovaries  are  affected  in  a  similar 
manner. 

THE    NAILS. 

Affections  of  the  nails  are  not  so  common  in  hereditary 
as  in  acquired  syphilis. 

There  are  two  forms  of  onychia:  the  ulcerative  and  the 
non-idcerative. 

Ulcerative  onychia  usually  occurs  during  the  first  and 
second  years  of  the  disease,  but  may  appear  much  later. 

It  is  the  most  common  form,  and  begins  at  the  side  or 
base  of  the  nail  as  a  papule  or  pustide,  which  ulcerates  and 


346  LESIONS  OF  HEREDITARY  SYPHILIS 

extends  along  the  base  or  margins  of  thr  nail,  and  finally 
involves  the  matrix,  which  results  in  the  loss  of  the  nail, 
thus  leaving  an  imhealthydooking  ulcer,  with  sanious  dis- 
charge. The  terminal  phalanx  becomes  red,  enlarged,  and 
painful. 

The  nails  of  the  fingers  are  more  liable  to  be  attacked  than 
those  of  the  toes. 

Cicatrization  of  the  ulcer,  without  the  formation  of  a  new- 
nail,  sometimes  follows,  or  a  deformed  and  useless  one  may 
grow. 

Non-iilccraticc  onychia  is  a  later  and  more  chronic  mani- 
festation. 

It  commences  as  a  coppery-colored  swelling  at  the  margin 
or  base  of  the  nail,  which  soon  becomes  thickened,  fissured, 
and  brittle,  dirty  white  in  color,  with  hyperemia  of  the 
matrix  and  adjoining  tissues.  There  is  usually  some  de- 
formity of  the  phalanx,  which  may  or  may  not  be  permanent. 

THE    TEETH. 

The  permanent  teeth  in  hereditary  syphilis  may  present 
certain  peculiarities,  especially  the  upper  central  incisors 
of  the  second  set,  which  are  known  as  Hutchinson's  teeth. 
(Fig.  133). 

In  describing  these  teeth  Hutchinson  says:  "As  diag- 
nostic of  hereditary  syphilis,  various  peculiarities  are  often 
presented  by  the  other  teeth,  especially  the  canines,  but  the 
upper  central  incisors  are  the  test  teeth.  When  first  cut 
these  teeth  are  usually  short,  narrow  from  side  to  side  at 
their  edges,  and  very  thin.  After  a  while  a  crescentic  por- 
tion from  their  edges  breaks  away,  lea^'ing  a  broad,  shallow, 
vertical   notch,   which  is  permanent  for  some  years,   but 


Tlll<:   liONICH 


'Ml 


between  twenty  Jind  thirty  usually  becomes  oMiteruted  l>y 
the  premature  wenring  down  of  the  tooth.  The  two  t(;eth 
often  coiiverg(^  and  sometimes  they  stiind  \\id(l.\  ;\\r,\r\.  In 
certahi  instiinccs  in  wliicl)  tlie  noteiiing  is  either  wholl\' 
absent  or  but  slightly  marked,  there  is  still  a  peculiar  color 
and  a  narrow  squareness  of  form,  which  are  easily  recognized 
by  the  practised  eye." 

The  first  or  temporary  set  of  teeth  do  not  show  this  mal- 
formation, and  many  children  sufi'ering  from  hereditary 
syphilis  have  perfectly  normal  permanent  teeth. 


Fig.  133. — Hutchinson's  teeth. 


THE    HAIR. 


Affections  of  the  hair  in  hereditary  syphilis  are  very  like 
those  in  the  acquired  form.  They  occur  with  lesions  of  the 
scalp,  especially  the  pustular  syphilide. 


THE    BONES. 

Osteochondritis. — This  affection  occurs  either  in  the  first 
months  of  the  disease  or  as  late  as  the  twelfth  year,  and 
is  a  very  constant  manifestation  of  untreated  hereditary 
syphilis. 


348  LESIONS  OF  HEREDITARY  SYPHILIS 

It  most  coniinouly  attacks  the  bones  of  the  forearm,  the 
leg,  the  arm.  and  tlie  thigh,  but  the  clavicle,  the  sternum, 
the  ril)s,  the  metacarpal  and  the  metatarsal  bones  may  also 
be  involved. 

The  lesion  is  situated  at  the  diaphyso-epiphyseal  jniiction, 
and  consists  of  a  ring-shaped  swelling  around  the  end  of  the 
bone.  In  some  cases  the  entire  epiphysis  may  be  enlargetl, 
with  or  without  the  ring-formation  at  its  junction  with  the 
shaft.  If  two  bones  are  att'ected,  as  those  of  the  forearm  or 
the  leg,  they  appear  to  be  fused  together  by  this  j^rocess. 
The  distal  ends  of  the  bones  are  more  frequently  attacked 
than  the  proximal. 

The  lesion  develops  slowly  in  some  cases,  and  rapidly  in 
others;  causes  but  little  pain,  interferes  only  slightly  with 
motion,  and  disappears  under  proper  treatment.  The  in- 
tegument is  not  involved  unless  the  mass  be  very  large, 
when  it  is  rendered  tense  and  painful.  The  joints  may  be 
secondarily  invaded,  especially  the  elbow-  and  knee-joint. 

In  some  cases  the  lesions  degenerate  and  break  down, 
causing  ulcerations  of  the  integument;  the  epiphysis  may 
be  separated  from  the  shaft  and  destroyed,  likewise  the 
cartilage.  In  other  cases  resolution  of  the  swellings  occurs, 
and  the  bone  returns  to  its  normal  condition;  but  if  the 
intermediate  layer  of  cartilage  be  destroyed,  the  bone  is 
usually   shortened. 

Periostitis  is  a  later  affection,  and  usually  appears  between 
tiie  fourth  and  nineteenth  years. 

Any  of  the  long  bones  may  be  affected,  and  in  some  cases 
those  of  the  skull  also.  The  bone  becomes  tender,  enlarged, 
and  curved  anteriorly;  the  process  may  invohe  the  entire 
length  of  the  shaft,  or  be  localized  and  i)roduce  nodes.  One 
or  both  limbs  can  be  thus  afi'ected. 


77//';  i']Yi<:>H  :i19 

Dactylitis.  'V\\v  lesions  consist  of  swcllinji;  ol'  (he  |)li;il;iiif^('s, 
iind  of  (he  metacarpal  or  metatarsal  bones  in  lliee;irl.\-  niontlis 
ol"  the  (lisetise,  or  even  n,s  late  as  the  tvv<;ntieth  ye;ir. 

The  proximal  i)lialanges  are  more  often  attacked  than  tli(' 
distal  ones.  The  course  of  this  affection  is  chronic,  unless 
treated. 

THE  SHEATHS  OF  THE  TENDONS. 

The  sheaths  of  the  tendons  may  become  swollen  and  iilled 
with  fluid,  the  overlying  skin  being  distended  and  reddened. 
This  affection  comes  on  rapidly,  is  not  readily  influenced  by 
antisyphilitic  treatment,  and  runs  a  chronic  course. 

THE  JOINTS. 

In  some  cases  of  osteochondritis  there  is  a  serous  effusion 
into  the  neighboring  joint,  which  becomes  slightly  painful 
on  account  of  the  tension ;  resorption  and  complete  recovery 
usually  ensue.  The  elbow,  the  wrist,  the  shoulder,  the  knee, 
and  the  ankle  are  most  frequently  involved,  although  almost 
any  articulation  is  liable  to  invasion. 

In  the  latter  years  of  syphilis  the  larger  joints  may  be 
affected  either  primarily  or  secondarily  to  lesions  of  the 
bones.  The  process  is  slow,  the  joint  being  greatly  distended 
and  slightly  painful;  the  surrounding  skin  remains  normal. 
With  the  proper  treatmen.t  resolution  generally  takes  place, 
leaving  a  good  articulation. 

THE   EYES. 

In  hereditary  syphilis  the  eyelids  and  the  eye  itself  are 
liable  to  all  of  the  lesions  which  occur  in  the  acquired  form, 


350  LESIOXS  OF  HEREDrTARY  SYPHILIS 

andAvhich  have  already  been  described  iiikUt  that  heading. 
These  affections  may  a])iH'ar  at  a  very  early  date. 


THE   EARS. 

The  occurrence  of  suddiii  deafness  in  children  who  have 
hereditary  syphilis  is  (juite  common.  It  is  apparently  due 
to  disease  of  the  nerves,  or  of  their  distributions  in  the  laby- 
rmth.  The  changes  in  the  external  parts,  or  the  membrana 
tympani,  are  not  sufficient  to  account  for  the  deafness;  the 
Eustachian  tubes  also  remain  normal. 

Deafness,  when  it  occurs,  is  usually  observed  from  about 
the  tenth  to  the  twentieth  year.  The  prognosis  is,  as  a  rule, 
unfavorable. 

THE    NERVOUS    SYSTEM. 

In  hereditary  syphilis  inflammation  of  the  meninges  and 
endarteritis  have  been  observed;  also  gummata  upon  the 
membranes. 

Chorea  sometimes  occurs,  and  is  either  mild  or  severe  in 
character;  it  may  be  accompanied  by  hemiplegia  or  epilepsy. 
In  these  cases  it  is  thought  that  hemiplegia  is  caused  by 
obstruction  of  the  middle  cerebral  artery;  that  chorea  is  due 
to  occlusion  of  its  small  distal  branches,  and  that  epilepsy 
is  occasioned  by  thickening  of  the  meninges  or  by  gummata 
in  or  near  the  corpus  striatum. 

Epilepsy  may  occur  alone,  and  has  been  observed  as  late 
as  the  fifteenth  year. 

There  is  sometimes  paralysis  of  the  cranial  nerves. 


TREATMENT  OF   II  ICIilChlTA  llY   SY  I'll  I  LIS         '.\.)\ 

HEMORRHAGIC    SYPHILIS    IN    NEWBORN    CHILDREN. 

Tliis  coiidilioii  exists  at  l)irtli,  or  not  later  than  the  first 
iiiontii  of  life,  and  is  frwiiiently  tlu^  only  rnanifestution  of 
the  disease,  l)ut  it  may  he  accompanied  hy  otlier  lesions. 

In  some  cases  there  is  a  sniajl,  subcutaneous  iicinorrhage 
in  parts  exposed  to  friction  or  pressure,  while  in  other  cases 
it  occurs  in  or  upon  mucous  membranes  and  viscera,  or  from 
the  umbilical  vein,  and  may  be  profuse  or  even  fatal. 


TREATMENT    OF   HEREDITARY    SYPHILIS. 

If  a  pregnant  woman  is  syphilitic,  she  should  immediately 
be  given  the  constitutional  treatment  outhned  in  the  chapters 
on  Acquired  Syphilis,  and  this  should  be  continued  in  a  care- 
ful and  methodical  manner  during  her  pregnancy,  and  there- 
after until  she  is  pronounced  free  from  the  disease. 

The  mother's  genitals  must  be  kept  in  a  healthy,  clean 
condition,  and,  if  lesions  exist  upon  or  around  them,  should 
receive  active  and  appropriate  local  treatment,  by  means  of 
hot  bichloride  douches,  calomel  dusting  powders,  and,  in 
some  cases,  applications  of  mercurial  ointment,  if  indicated. 

When  these  measures  are  taken  early  enough  in  the  preg- 
nane}^, infection  of  the  fetus  may  usually  be  avoided.  After 
the  fifth  or  sixth  month,  however,  the  child  is  very  liable  to 
contract  the  disease,  and  even  if  apparently  perfectly  healthy 
at  birth,  should  be  considered  as  possibly  syphilitic  and  kept 
under  careful  observation,  with  repeated  blood  examinations, 
and  a  vigilant  watch  for  the  development  of  lesions. 

If  the  father  was  syphilitic  at  the  time  of  impregnation 
or  showed  any  manifestation  of  syphilis  before  it,  then  the 


352  LESIONS  OF  HEREDITARY  SYPHILIS 

mother  must  litive  antisyphilitic  treatment  in  the  maimer 
above  described  for  its  beneficial  etl'cct  both  on  the  fetus 
and  herself. 

In  treating  syphilitic  infants  great  care  must  be  used,  as 
the  use  of  inunctions  is  sometimes  difficult  on  accoimt  of 
the  delicacy  and  irritability  of  tlie  skin,  and  the  development 
of  gastro-intestinal  irritation. 

Treatment  of  the  child  by  means  of  the  milk  of  the  mother 
or  nurse  is  known  as  indirect  treatment.  Although  some  of 
the  drug  may  be  eliminated  through  the  milk  of  the  nursing 
woman,  it  is  at  best  an  uncertain  and  inaccurate  method 
of  treatment^  and  one  not  to  be  relied  upon.  It  must  not  be 
forgotten  that  a  healthy  wet-nurse  is  very  liable  to  infection 
on  the  breast  or  nipple  by  nursing  such  children. 

The  direct  treatment  of  the  child  should  be  intermittent 
and  not  continuous  in  character;  during  the  intervals  of 
treatment  it  is  well  to  admhiister  tonics,  and  to  do  all  in  our 
power  to  build  up  the  general  condition. 

As  in  the  case  of  adults  the  treatment  should  include  the 
compoimd  use  of  salvarsan  or  neosalvarsan,  mercury  and 
iodide  of  potash.  The  dosage  of  salvarsan  in  the  case  of  an 
infant  should  run  from  0.01  to  0.02  gm.;  that  of  neosalvar- 
san may  be  slightly  higher,  and  these  should  be  cautiously 
re])eated  at  intervals  according  to  the  condition  and  suscep- 
tibility of  the  child. 

For  inunctions  we  employ  50  per  cent,  mercurial  oint- 
ment, using  from  10  to  20  grains  every  day,  or  every  other 
daj',  according  to  the  age  and  condition  of  the  child. 

The  administration  of  mercury  by  intramuscular  injection 
is  too  painful  a  method  tb  be  employed  for  children. 

Potassium  iodide  is  best  administered  in  the  chikl's  bottle 
of  milk.    The  dosage  for  an  infant  is  from  0.5  to  1  gr.,  or 


TUEATMI<:NT  of   ll/'Jh'/'JD/'I'Ah'V  SY  I'll  I  LIS  '.\')'.\ 

even  more,  lliree  limes  ii  diiy.  In  hnjisl-lcd  inl'iinls  it  ni;i\' 
1)0  given  dissolved  in  water,  with  a  little  sngar  oi'  milk. 

The  internal  adnn'nistnition  of  merenry  m;iy  oeeasionally 
have  to  be  resorted  to,  hnt,  iis  in  iidnlls,  this  method  is 
neither  satisfactory  nor  a(l\'is;d)lc,  iind  slionid  only  he  nsed 
when  no  other  is  possible. 

If  the  syphilides  are  very  persistent,  jnucii  benefit  is  always 
derived  from  their  local  treatment  by  fumigations,  ointments, 
lotions,  or  baths  containing  mercury;  at  the  same  time  keep- 
ing the  lesions  scrupulously  clean. 

Constitutional  treatment  should  always  be  employed  for 
at  least  two  years,  and  continued  for  several  months  after 
all  manifestations  of  the  disease  have  disappeared;  the 
Wassermann  reaction  being  taken  at  intervals  for  several 
years  thereafter. 


23 


INDEX. 


Abscess,  cuiiiplicating  stricture  of 
urethra,  131 
periurethral,  56 
of  prostate,  64 
rupture  of,  64 
situation,  64 
symptoms  of,  64 
treatment  of,  67,  68 
Adenitis  complicating  urethritis,  61 
Albargin,  45 

Alimentary  canal,  syphilis  of,  344 
Allis's  clamp,  172 
Alopecia,  263 
prognosis  of,  263 
symptoms  of,  263 
varieties  of,  263 
Anus,  syphilitic  lesions  of,  274 
Argyrol,  45 

Arnott's  grooved  director,  167 
Arthralgia,  304 
Arthritis,     gonorrheal,     107.     See 

Gonorrheal  arthritis. 
Aspiration  of  bladder,  180 


B 


Balanitis,  51 

diagnosed  from  acute  gonorrhea, 

30 
treatment  of,  51 
Balanoposthitis,  51 

diagnosed  from  acute  gonorrhea, 

30 
infected,  231 
Bladder,  aspiration  of,  180 

diverticula  of,  complicatingstrict- 
ure  of  urethra,  131 


Jiloodvessels,  sy])hilis  of,  283 
Bones,  syphilis  of,  301,  347 
Bougies,  140,  144,  153 
h  boule,  141 

method  of  passing,  144,  149 
care  of,  189,  190 
filiform,  141,  152,  153,  165 
care  of,  190 

method  of  passing,  149 
olivary,  140,  152,  153 
Bronchi,  syphilis  of,  280 


Catheter  carriers,  193 

fever,  185.  See  Urinary  fever. 
Catheterization,  retrograde,  174 
Catheters,  182 

bicoude,  181,  182 

blunt,  178 

bulbous,  46 

care  of,  191 

coude,  181,  182 

instillation,  96 

olivary.  178,  182 

sUver,  183,  191 

with  prostatic  curve,  183 

soft-rubber,  46,  87,  191,  192 

tunnelled,  180,  191 

ureteral,  194 

woven,  191 
Chancre,  228.     See  Syphilis,  initial 
lesion. 

diagnosed  from  chancroid,  235 

differential  diagnosis  of,  235 

extragenital,  229 

genital,  229 

hard,  228 

Hunterian,  228 


356 


INDEX 


Chaftoro    of    meatus    or    urethra, 
iliagnoscd  from  acute  gonor- 
rhea, 30 
soft,  208.     See  Chancroid, 
synonyms  of,  228 
Chancroid,  208 

characteristics  of,  209 
compUcations  of,  211 
adenitis,  212 
lymphangitis,  211 
lUlTerential  iliagnosis  of,  212,  235 
abrasions,  213 
chafes,  213 

exulccrated  bahmitis,  212 
fissures,  213 
gonorrhea,  31 
hard  chancre,  212,  235 
herpetic  vesicles,  212 
duration  of,  210 
etiology  of,  208 

bacillus  of  Ducrey,  209 
infection  of,  208 
direct,  208 
mediate,  208 
prognosis  of,  213 
scat  of,  210 
treatment  of,  213 
of  adenitis,  217 
first  method,  217 
second  method,  218 
general,  213 
of  the  sore,  214 

beneath  prepuce,  215 
of  urethra,  214 
varieties  of,  210 
echthymatous,  211 
follicular  or  acneforni,   210 
phagedenic,  211 
Chordee,  26 

to  relieve,  43 
Circulatory  organs,  syphilis  of,  282 
Circumcision,  205 
Clamp,  Hayden's,  206 
Colles's  law,  342 
Condylomata,  240,  268,  340 
Congenital    syphilis,     336.     See 

Hereditary  syphilis. 
Cowperitis,  59 
suppurative,  60 
treatment  of,  60 
Crede's  method  of  treating  gonor- 
rheal ophthalmia,  105 


Cystitis,  80 
gonorrheal,  SO 
symptoms  of,  81 
acute,  81 
chronic,  81 
subacute,  81 
urine,  81 
treatment  of,  SI 
acute  stage,  81 
chronic  stage,  82 
irrigations,  82 


Dactylitis,  298,  349 

varieties  of,  298 
Digestive  organs,  syphilis  of,  2()9 
Dilatation  of  ureters  complicating 
stricture  of  urethra,  132 
of  urethra,  152-156 
continuous,  154 
gradual,  153 

complications  of,  154 
instruments,  153 
medication,  154 
rapid,  154 
Diverticula  of  bladder  complicat- 
ing stricture  of  urethra,  131 
Divulsion,  156 

Dressings  in  acute  gonorrhea,  37, 
39,  40,  41,  42 


E 

Kars,  syphilis  of,  314,  349 
Electrolysis,  156 
Endoscope,  97-101 

care  of,  189 
Endoscopy,  97 

indications  for,  97 

method  of,  101 
Epididymitis,  71,  284 

lesions  of,  284 

symptoms  of,  72 

treatment  of,  73 
Epididymo-orchitis,  71 

dressing  for,  74 

symptoms  of,  72 

treatment  of,  73 
Episcleritis,  309 


INDEX 


'.\r{i 


IOr'(u'.M()iis,  piiiiil'iil,  'J(') 

l(}  r(!li(!vo,  4.'i 
l<:rytlierna,  'i.'iS,  2(57,  2(i!),  27:i,  27S 
Esophagus,    sy[)liilit.ic    lesions    of, 

274    ■ 
Extravasation  ol'  urine,  182 

(lauses  of,  132 

regions  of,  132 

symptoms  of,  133 
constitutional,  133 
local,  133 

treatment  of,  136 
Eye,  syphilis  of,  306,  349 


Fever,  catheter,  185.     *See  Urinary 
fever. 

syphilitic,  236 

urethral,  185.    S&e,  Urinary  fever. 

urinary,  185.    See  Urinary  fever. 
Filiforms,  care  of,  190 

to  pass,  149 

to  tie  in,  179 
Fistula},   complicating  stricture  of 

urethra,  131 
Folliculitis,  57 

paraurethral,  58 

penile,  57 

preputial,  57,  58 

treatment,  58,  59 
Fluhrer's  urethrotome,  159,  160 


G 


Genito-urinary    organs,    syphilis 

of,  284,  345 
Glaus  penis,  affections  of,  198 
Gleet,  84.    ^ee  Gonorrhea,  chronic. 
Glycerin  as  a  lubricant,  195 
Gonococcus,  19,  20 
progress  of,  22 
staining  of,  20,  21 
Gonorrhea,  17 
acute,  24 
anterior,  24 

complications  of,  51-62 
stages  of,  25 
acute,  25 
declining,  26 


Gonorrhea,  acute,  .uiUirior,  Hta^faj 
of,  pro(lrotii;il,  25 
symptoms  of,  25 
incubation,  24 
opacity  of  urine,  I'O 
two-glass  test,  28 
tr(!atm(!n(,  of,  32,  37 
abortive!,  32 
of  declining  stage,  43 
dressings,  37,   39,   40,  41, 

42 
hand-injections,  43 
internal  medication,  43 
irrigations,  43 
Janet's  method,  35 
anteroposterior,  24 
diagnosis  of,  30 
posterior,  27 

complications  of,  63-83 
prognosis  of,  31 
treatment  of,  48 
two-glass  test,  28 
retention  of  urine  during,  177 
chronic,  84 

anterior,  84,  86 
symptoms  of,  86 
treatment  of,  90 
irrigations,  90 
sounds,  92 
anteroposterior,  84 
causes,  84 
lesions,  84 
posterior,  87 
symptoms  of,  88 
treatment  of,  92 
instillations,  95 
irrigations,  93 

amount  of  fluid,  94 
solutions,  94 
treatment  of,  89 
varieties  of,  according  to  loca- 
tion, 84 
anterior,  84 
anteroposterior,  84 
posterior,  84 
urethrocystitis,  84 
complications  of,  25 
com-se  of,  24 
definition  of,  17 
diagnosis  of,  30 
differential,  30 
balanitis,  30 


358 


INDEX 


il)taiiiiiifi, 


Cion6rrlu>:i,  diagnosis   of,  diiTeriMi- 
cntial  rhaiK'ie,  30 
cIiaiKToid,  ;U 
etiology  of,  19 
diploc'occ'us,  21 
goiioc'occus,  19,  20.    Sec  Cioiio- 

C'OCCUS. 

otlior  microorganisms,  HI 
localities,  17 
Dcriirrcncc,  17 
jjathology,  22 
))rogiiosis,  ol 
smear,     metlitxl     of 
20 
of  staining,  21 
when  cured,  101 
Gonorrheal  arthritis,  107 
bacteriology  of,  107 
cause  of,  107 
diagnosis  of,  111 
frequency  of,  108 
joint  lesions  of,  109 
muscles,  111 
liathology  of,  108 
symptoms  of,  109 
treatment  of,  112 
vaccines  in,  113 
flakes  or  shreds,  86 
anterior  urethra,  87 
])<)sterior  urethra,  87 
ophthalmia,  104 
cause  of,  104 
prognosis  of,  105 
symptoms  of,  104 
treatment  of,  105 
rheumatism,    107.      See    Clonor- 
rlical  arthritis. 
Ciouley's  bistoury,  159 

tunnelled  catheter  and  guide,  180 
sound  and  filiform,  155 
Cunnnata,     255.     257,     341.       See 
Syi)hilide,  gummatous, 
of  soft  palate,  273 
of  tongue,  271 
Gummatous  ulcers,  258,  341 


Hairs,  syphilis  affecting,  263,  347 
Hand-injections,  43 
Hanover  urethral  syringe,  44 


Ilayden's     l)ladder     sj'ringc     and 

coupler,  33 
briilge  for  inflameil  testicle,  73 
circumcision  clam]),  206 
doulile-currciit    irrigation    tubes, 

65 


for 


cpididyino-orcliitis 


instillatidii  syringe,  34 
sovmd,  139 

statT  and  liliform,  165 
three-way  stopcock,  329 
trocar  and  caimula,  181 
urethral  forceps,  193 
uretinoscope,  99 
Hemorrhagic  syphilis  in  newboiii 

children,  351 
Hereditary  syi)hilis,  223,  336 
abortion,  338 

appearance  of  symptoms,  336 
Colles's  law  in,  342 
course  of,  337 
definition  of,  336 
derivation  of,  336 
duration  of,  337 
hemorrhagic,  in  newborn  clul- 

dren,  351 
lesions  of,  339 

alimentary  canal,  344 
bones,  347 
condylomata,  340 
dactylitis,  349 
ears,  350 
eyes,  349 

genito-urinary  organs,  345 
gummata,  341 
gummatous      infiltrations, 
343 
ulcers,  341 
hairs,  347 
joints,  349 
kidneys,  345 
larvnx,  343 
liv('"r,  344 
I  lungs,  343 

mucous  membranes,  341 
!  nasal,  341 

jxitches,  342 
nails,  345 

nervous  system,  350 
chorea,  350 
epilejjs}',  350 


INDEX 


'.'y')\) 


llcrcililMU-y  H.ypliilis,  lesions  of,  ner- 
vous  syst,!!tn,    hciiiipli'- 

inciiiiigos,  .'350 
ptinilysis       ol'       cniniiil 
nerves,  'Mi{) 
osteochondritis,   'Ml,   ^W.) 
piincreas,  'MA 
periostitis,  ;M8 
respiratory  organs,  'M'i 
spleen,  :i44 
syi)liili.les,  339-341 
bullous,  341 
erythematous,  339 
furuncular,  340 
papular,  339 
pustular,  340 
tubercular,  341 
vesicular,  340 
teeth,  346 

tendon  sheaths,  349 
testicles,  345 
mortality,  338 
prognosis  of,  338 
snuffling,  341 
transmission  of,  337 
treatment  of,  351 
direct,  352 

fumigations,  353 
intramuscular  injections, 

352 
mixed  treatment,  352 
neosalvarsan,  352 
salvarsan,  352 
duration,  353 
father  syphilitic,  351 
indirect,  352 
pregnant  woman,  351 
Herpes  progenitalis,  198 
cause  of,  198 
diagnosis  of,  199 
lesion  of,  198 
prognosis  of,  199 
symptoms  of,  199 
treatment  of,  200 
Hutchinson's  teeth,  346,  347 


Instillation  catheter,  96 
Instillations,  95 
Instrumentation,  195 


Instrutnetits,     ISS.      Sec    I'retlirai 

instrunierils. 
Intestines,  sypliilitic  lesifjiis  fif,  271 
Iritis,  :',();» 

acute,  :',)() 

chronic,  31  I 

parenchymatous  or  suf)f)urative, 

310 
serous,  310 
simple  or  plastic,  ^jIO 
Irrigation,  33,  43,  46,  82,  90,  93 
solutions,  91 


Jankt's  method  of  treating  acute 

gonorrhea,  35 
Joints,  syphilis  affecting,  301,  304, 

349 


Kollman's  dilators,  155 
Keratitis,  308 

diffuse,  308 

punctate,  309 
Kidneys,  syphilis  affecting,  345 


Larynx,  syphilis  affecting,  278, 343 

Litholapaxy  tubes,  care  of,  191 

Lithotrites,  care  of,  190 

Liver,  syphilis  affecting,  275,  344 

Lubricants,  194 
glycerin,  195 
lubrichondrin,  195 
olive  oil,  195 
white  vaseline,  195 

Lubrichondrin  as  a  lubricant,  195 

Lungs,  sj'philis  affecting,  280,  343 

Luy's  urethroscope,  98 

Lymphangitis  complicating  ureth- 
ritis, 61 

M 

Macular  syphilide.  238 
Maisonneuve's   urethrotome,    158, 
159 


360 


IXDEX 


Meatotoiny,  lo7 

Meatus  souiul,  157 

Mixed  sore,  '2Vi 

Moutli,  syphilis  of,  2l)9 

Mucous  papules,  '2(37.    See  Mucous 

patches, 
pat  dies,  2t)7.  342 

complications  of,  268 

of  larynx.  279 

lesions  of,  2l)S 

of  toiiffue,  2l)9 

\vithii\  the  month,  2{i8 
Myositis,  291) 


N 


Nails,  .syphilitic    lesions    of,  263i 

34o 
Neosalvarsan,  320,  352 
Nervous  system,  syphilis  affecting, 

288,  350 
Nose,  syphilis  affecting,  278 


Olive  oil  Us  a  lubricant,  195 
Onychia,  264,  345 

non-ulcerative,  346 

separation  of  the  nail,  264 

sicca,  264 

ulcerative,  345 
Opacity  of  urine,  30 
Ophthalmia,  gonorrheal,  104.     See 
(loiiorrheal  o))hthalmia. 

neonatorum,    104.      Sec    Gonor- 
rheal ophthalmia. 
Orchitis,  284 

circumscribed,  285 

course  of,  285 

differential  diagnosis  of,  286 

diffuse  of,  285 

site  of,  284 

symptoms  of,  285 
Osteochondritis,  347,  349 
Otis's     perineal     drainage     tube, 
169 

urethrometer,  141 

urethrotome,  160 


P.\L.\TK,  guinmata  of,  273 
Pancreas,   syphilis    affecting,    277, 

344 
Paraphimosis,  53 

treatment  of,  54,  55 
Paraurethral  folliculitis,  58 
Perineal  .section,  173 
Perionj'chia,  265 

non-ulcerative,  265 

ulcerative,  265. 
Periostitis,  348 
Periurethral  abscess,  56 

treatment  of,  57 
Pharynx,  syphilitic  lesions  of,  273 
Phimosis,  52 

accjuired,  52 

congenital,  52,  205 

sci-ssors,  215 
Prepuce,  affections  of,  198 
Preputial  folliculitis,  58 
Pro.state,  abscess  of,  64 
treatment  of,  67,  68 

congestion,  63,  68 

inflammation,  63,  68.    See  Pros- 
tatitis. 
Prostatitis,  acute,  63 
sj^mptoms  of,  63 
treatment  of,  64 

chronic,  68 

diagnosis  of,  69 
symptoms  of,  69 
treatment  of,  70 
Protargol,  45 
Pus  in  urine,  29 
Pyelitis,  83 
Pyelonephritis,  83 
Pyuria,  29 


R 


Radlsh  finger.  111 
Rectal  electrode,  71 
Respiratory  organs,  syphilis  affect- 
ing, 278,  343 
Retention  of  urine,  176 
causation,  176 
effects  on  mucous  nieml)rane, 

177 
treatment  of,  177 


INDf'JX 


301 


liclciil-ioii   of    iiriiii',    I  rc'i.tincnr    oC, 
;is|)ir;i.t,ii)ii,   ISO 
(lui'injj;  ;i,(;ul.c  H()]\()iy\]ci\.,  177 
wIk'm    <;;iiis(mI    by   si  rid  mc, 

17S 
vvlien  due,    l.o  prosl.alic    hy- 
]K:rl.n)|)liy,  \Ki 
Rctrogrado  ciiUu'tcri/i.'il.ion,  171 
Rheuiiiahisin,  }i;()iK)iTh(!al,  107.    Sac 

Gonorrheal  arthi-itis. 
Rupia,  252 
cicatrices,  25;:5 
lesion,  252 
varieties,  252 


Salivation,  325 
synii)toms  of,  325 
treatment  of,  32() 
Salvarsan,  administration  of,  326, 
352 
gravity  apparatus,  328 
Scale  plate,  138 
Schreiber's  needle,  329 
Seminal  vesiculitis,  76 
acute,  76 
chronic,  77 
Serum  in  treatment  of  gonorrheal 

arthritis,  114 
Silk  bulbous  instillation  catheter, 

96 
Smear,  to  take,  20 
Smoker's  patches  or  plaques,   269 
Snuffling,  341 

Soft  palate,  gummata  of,  273 
Sounds,  92,  140,  189 
care  of,  189 
meatus,  157 
method  of  passing,  144 
Spermatocystitis,  76.    See  Seminal 

vesiculitis. 
Spirocheta  pallida,  221,  222 

refringens,  222 
Spleen,  syphilis  affecting,  276,  344 
Stricture  of  the  urethra,  115 
complications  of,  130,  154 
abscesses,  131 
diverticula  of  bladder,  131 
extravasation  of  urine,  132. 
See  Extravasation  of  urine. 


Slnt-liirc  III    IIk;  iir'cl  lir;i,  (;oiriplif;i- 
tioD.M  of,  listiila;,   K'jI 
uret(!r.s,  dilatation  of,  K>2 
diiignosis  of,  l.'iX 
idHtnuMcntH,  \'.W 
incthod  of  passing  a  sound, 

144 
preliminary  examination,  142 
urethral  exploration,    \'V.', 
etiology  f)f,  118 
forms  of,  125 
ainiular,  125 
congenital,  118,  119 
irregular,  125 
linear,  125 
semifibrous,  121 
soft,  121 
spasmodic,  126 
tortuous,  125 
traumatic,  118 
gonorrheal,  118,  120 
number,  120 
pathology  of,  121 
seat  of,  119 

region,  119 
symptoms  of,  127 
time  of  occurrence  of,  121 
treatment  of,  151 
bevond penoscrotal  junction, 

152 
congenital,  151 
dilatation,  152,  153 
continuous,  154 
gradual,  153 
rapid,  154 
divulsion,  156 
electrotysis,  156 
meatotomy,  157 
near  the  meatus,  152 
penile  urethra,  152 
perineal  section,  173 
retrograde     catheterization, 

174 
traumatic,  151 
urethrectomj",  157 
urethrotomy,  158,  163.  See 
I'rethrotomj-. 
Suspensory  bandages,  8 
Svnovitis,  305 
Svphilides,  237,  339 
bullous,  253,  341 
course,  238 


362 


IXDEX 


Sypluliilos,  orytheinatous,  2:^8,  339. 
Sec  Erythema. 

lesion,  23'J 

site,  239 

synonyms,  23S 
f!;innmat<)us,  255 

precocious,  255 
varieties  of,  255 

tertiary.  255 
Miacular,  23S 
niaculopapular,  213 
nuiliiiiiant  ])ref'ocious,  2l)l 

ileliaition  of,  2(jl 

occurrence  of,  261 

symptoms  of,  261 

varieties  of,  261 
I)apular,  241,  339 

conical  or  miliary,  241 

lenticular  or  flat,  242 

lesion,  241 

scaling  of  palms  and  soles,  245 
course,  245 

varieties,  241 
l)ip;mentary,  260 

forms  of,  260 
IHistuhir,  248,  340 

acncform,  248 

ectliymaform,  251 

imj^etigoform,  249 

variolaform,  250 
rupia,  252.    See  Rupia. 
serpiginous,  250,  259 

deep,  260 

superficial,  259 
tubercular,  253,  341 

forms,  253 
Syphilis,  221 
acquired,  223 
adenitis,    234.      See    Syphilitic 

adenitis, 
arthralgia,  .304 
of  bloodvessels,  283 
of  bones,  cartilages,  and  joints, 

301 
of  bronchi,  280 
of  circulatory  organs,  282 
congenital,  336.    See  Hereditary 

syphilis, 
constitutional  treatment  of,  316- 
335 
baths,  317 
diet  and  daily  habits,  316 


Syphilis,  constitutional,  treatmiMit 
of,  duration,  334 
iodide  of  potash,  323 

iodism,  324 
merciuT,  318 

com]  )licat  ions  of,  318 
fumigation,  321 
iTitraiiiuscular    injections, 

322 
inunction,  319 
regions,  320 
by  mouth,  318 
mixed  treatment,  324 
neosalvarsan,  318,  326,  352 
intramuscularly,  327 
intravenously,  327 
primary  stage,  317 

anemia,  317 
salivation,    325.     See   Saliva- 
tion, 
salvarsan,  318,  326,  332,  352 
Wassermann  reaction,  335 
Zittmann's  decoction,  325 
contagion,  224 
cutaneous    manifestations,    237. 

See  Syphilides. 
of  digestive  organs,  269 
of  ear,  314 

external  auditory  canal,  314 
internal  car,  315 
middle  ear,  314 
of  esophagus,  274 
etiology  of,  221 

Spirocheta  pallida,  221 
of  eye,  306 
choroid,  312 
ciliary  body,  311 
conjunctiva,  307,  308 
cornea,  308.    See  Keratitis, 
eyelids,  307 
iris,  309.    See  Iritis, 
lacrimal  glands,  307 

passages,  306 
muscles,  308 
nerves,  313 
optic  nerve,  313 
orbit,  306 
retina,  312 
sclerotic  coat,  309 
of   fingers  and   toes,   298.     See 

Dactylitis, 
of  geni to-urinary  organs,  284 


INDEX 


Syphilis  of  t^cnilo-uiiiuiry  orf^ans, 
epididymis,  'JSl.    Sec  I'lpi- 
(lidyrnilis. 
kidiK^ys,  12.S7 
|)(!nis,  '2S(') 

testicles,  2S1.     Hcc  Orcliitis. 
uterus  iuid  adiiexa,  2(S() 
of  hair,  20;-5.     Sec,  Alopecia, 
of  heart,  2S2 
lieinorrhaffic,    in    ncwhoru    ciiil- 

dren,  351 
hereditary,  223,  ;i3().    .S'ec  Hered- 
itary syphilis, 
incubation  period,  223 
infantile,   33(5.     See   Hereditary 

syphilis, 
infection,  225 

direct,  225 

mediate,  225 
initial  lesion,  228 

duration  of,  232 

induration  of,  231 
parchment,  232 
relapsing,  232 

origin  of,  228 

seat  of,  229 

secretion  of,  232 

termination  of,  231 

treatment  of,  233 
local,  233 

varieties  of,  231 
insontium,  225 
of  joints,  304 

arthralgia,  304 

synovitis,  305 
of  larjaix,  278 

chronic  inflammations,  279 

deep  ulcerations,  279 

erythema,  278 
■    mucous  patches,  279 

superficial  ulcerations,  279 

tertiary  lesions,  279 

vegetations,  279 
late  osseous  lesions,  302 

osteomyelitis,  304 

osteoperiostitis,  302 
of  liver,  275 
of  lungs,  280 

lymphangitis,  235.      See  Syphil- 
itic lymphangitis, 
of  maxillary  bones,  304 
of  mouth,  269 


Sy[jliilis  ol'  iiioiilli,  cryl  liciiia,  2(19 
mucous  pat(;li<!S,  2<19 
pajjulcH,  2(19 
vesicles,  2(»9 
of  truicoiiH  mcmhraneH,  2()7 

condyloiiiata,   208.     See  (Jori- 

(lylomata. 
erythema,  207.   See,  lOrythema. 
mucous     i)atches,     207.       See 
Mucous  patches, 
of  muscles,  296 
of  nails,  263.     See  (Jii\'clii;i  ihkI 

Perionychia. 
of  nervous  system,  288 
apha,sia,  292 

arachnoid  and  joia  mater,  289 
arteries,  289 
brain  and  cord,  289 
dura  mater,  288 
epilepsy,  291 
general  paralysis,  294 
hemiplegia,  290 
locomotor  ataxia,  293 
nerves,  290 
paraplegia,  292 
of  skull  and  vertebra;,  288 
syphilitic  tumors,  290 
of  nose,  278 
of  pancreas,  277 
of  pharynx,  273 
of  pleura,  281 

precocious  osseous  affections,  301 
prognosis  of,  226 
of  rectum,  274 
stricture,  275 
reinfection,  223 
of  respirator}'  organs,  278 
secondary  period,  236 
anemia,  237 
commencement,  236 
icterus,  237 
insomnia,  237 
neuralgic  pains,  236 
sensorj'  disturbances,  237 
syphihdes,   237.     See  Syphil- 

ides. 
syphilitic  fever,  236 
of  soft  palate,  273 
of  spleen,  276 
Spirocheta  pallida.  221 
stages  of,  223 
primary-,  223 


364 


INDEX 


Syphilis,  t^taRCs  of,  secondary,  224: 
tertiary,  224 
of  stoinacli  and  intestines,  274 
synovitis,  305 
of  tciuions,  sheaths,  ai)()neiiroses, 

and  l)ursa>,  2i>7 
of  toiifiue,  2tJll 

(hiTcMviitial  diagnosis  of,  271 
carciuonia,  272 
guinmata,  271 
initial  lesion,  271 
tubercular  ulcers,  272 
erythema,  2ti9 
fissures,  270 
gunnnata,  271 
mucous  patches,  269 
sclerosis,  270 
deep,  270    . 
superficial,  270 
of  trachea,  280 
Syphilitic  adenitis,  234 

situation  in  relation  to  chancre 

235 
symptoms,  234 
erythema,  238 
fever,  23(3 
lympliangitis,  235 

symptoms  of,  235 
roseola,  238 
Syringe  for  bladder,  33 
instillation,  34 
urethral,  44 


Taylor's  phimosis  scissors,  215 
Teale's  gorget,  167 
Teeth,  Hutchinson's,  346 
syphilitic  lesions  of,  346 
Thompson's  two-glass  test,  28 
Tongue,  syphilis  of,  269,  271 


U 


Ulcers,  gummatous,  258 
Ureteral  catheters,  care  of,  194 
Ureteritis,  83 
Ureters,  dilatation  of  complicating 

stricture  of  urethra,  132 
Urethra,  anatomy,  115 


Urethra,  caliber.  118 
divisions,  119 
length,  117 
portions,  116 
bulbous,  116 
fixed,  IK) 
memliranous,  1  Ki 
narrow,  1  17 

l)enile  or  i)enduious,  116 
prostatic,  116 
shape,  118 
stricture  of,  115.     See  Stricture 

of  the  urethra, 
structure  of,  115 
Uretliral  and  bladder  irrigation,  47 
fever,  185.     See  Urinary  fever, 
forceps,  Ilayden's,  193 
instillation,  95 
instruments,  188 
care  and  use,  188 
sterilization,  188 
bougies  i\  boule,  189 
catheters,  191 
silver,  191 
soft-rubber,  191 
tunnelled,  191 
ureteral,  194 
woven,  191 
cystoscopes,  193 
endoscopic  tubes,  189 
filiforms,  190 
lithotrites,  190 
olivary  bougies,  189 
sounds,  189 

tunnelled,  189 
syringes,  193 
urethrotomes,  190 
.sj'ringes,  44,  193 
Urethrectomy,  157 
Urethritis,  catarrhal,  19 
n()ii-si)ecific,  19 
specific,  17.     See  Gonorrhea. 
Urethrocystitis,  78 
acute,  79 
chronic,  79,  84 
symptoms  of,  79 
treatment  of,  80 
Urethrometer,  141 

method  of  u.se,  150 
Urethroscope,  97 
Hayden's,  99 
Luy's,  98 


INDEX 


'M\ri 


Urethrotoiiio,  fiun;  of,  I 'JO 
Fluhrcr's,  150,  HiO 
Maisoiiiiciivci's,  I^S,  If)'.) 
Otis'H,  IGO 
Urethrotomy,  158-175 
external,  163 

bladder  drainage,  1(>J 
indications,  1(J3 
method,  Ki^J 
indications,  103 
perineal  section,  173 

indications,  173 
preparation  of  patient,  163 
retrograde      catheterization, 

174 
with  a  guide,  165 
without  a  guide,  171 
internal,  158 
indications,  158 
instruments,  158 
urethrotomes,  158 
Fluhrer's,  159 
Maisomieuve's,  158 
Otis's,  160 
operation,  162 
preparation  of  patient,  161 
ITrinary  fever,  185 
etiology  of,  186 
prophylaxis  in,  186 
treatment  of,  186 
varieties  of,  185 
Urine,  extravasation  of,  132.     See 
Extravasation  of  urine, 
retention  of,  176.    See  Retention 
of  urine. 


Vaccines,  in  treatment  of  gonor- 
rheal arthriti.s,  113 

Vaseline  as  a  lubricant,  lO.j 

Vegetations,  200 
diagnosis  of,  203 
lesion,  201 
treatment  of,  204 

Venereal  wart.s,  201.     Sm  Vegeta- 
tions. 

Vesical  tenesmus,  28 

Vesiculitis,  76 

abscess  formation,  77 
chronic,  77 

diagnosis  of,  78 
symptoms  of,  77 
treatment  of,  78 
diagnosis  of,  76 

,    symptoms  of,  76 
treatment  of,  77 


W 

Warts,   200.     See  Vegetations. 

hard,  202 

soft,  201 
Wassermann's  reaction,  233,  271, 

276,  286,  295,  330,  335,  342,  353 


Zittmann's  decoction,  325 


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